Individual Health Plans Product Manual

Transcription

1 Individual Health Plans Product Manual

2 DISCLAIMER Agents/brokers interested in selling Medavie Blue Cross s personal health insurance plans can use this document as a training tool. Existing agents/brokers can use this document as reference material. This document is not a contract or policy and does not contain all information related to Medavie Blue Cross s personal health products. 2

3 Table of Contents Why a personal health plan?... 5 Options - Personal Health Plan Product Manual Principal Benefits Module (Mandatory)... 6 Extended Health Benefits... 6 Vision Care... 6 Physiotherapy... 6 Massage Therapy, Naturopath and Acupuncture... 7 Other Practitioners... 7 Ambulance or Ambulance Attendant... 7 Private-Duty Nursing... 7 Hearing Aids... 7 Diabetic Supplies... 7 Accidental Dental... 7 Medical Equipment... 8 Oxygen Equipment & Oxygen... 8 Prosthetic Appliances... 8 Orthopedic Shoes & Moulded Arch Supports... 8 Braces and Splints... 9 Ostomy Supplies... 9 Physician s Services Out-of-Province... 9 Accidental Death and Dismemberment Benefit Drug Module (Optional)... 9 Drug Module Without Deductible... 9 Drug Module With Deductible Dental Module (Optional)...10 Basic Dental Critical Care Module (Optional)...11 LifeLink Critical Conditions Benefit...11 Accidental Death & Dismemberment Benefit Hospital Cash Plan Module (Optional) Assured Access Module (Optional)...11 Options Plus - Personal Health Plan Product Manual Principal Benefits Module (Mandatory)...13 Hospital Benefits...13 Travel Benefits...13 Extended Health Benefits...14 Vision Care...14 Physiotherapy...14 Massage Therapy, Naturopath and Acupuncture...15 Other Practitioners...15 Ambulance or Ambulance Attendant...15 Private-Duty Nursing...15 Hearing Aids...15 Diabetic Supplies...15 Accidental Dental...16 Medical Equipment

4 Oxygen Equipment & Oxygen...16 Prosthetic Appliances...16 Orthopedic Shoes & Moulded Arch Supports...16 Braces and Splints...17 Ostomy Supplies...17 Physician s Services Out-of-Province...17 Accidental Death & Dismemberment Benefit Drug Module (Optional) Dental Module (Optional)...17 Basic Dental...17 Periodontal Services Benefit Critical Care Module (Optional)...18 LifeLink Critical Conditions Benefit...18 Accidental Death & Dismemberment Benefit...18 Hospital Cash Plan Benefit Assured Access Module (Optional)...19 Pre-Approved Life...19 General Information - Options/Options Plus Personal Health Plans...20 Application Procedure...20 Pre-Existing Conditions...20 Waiting Periods...20 Benefits...21 Eligibility...21 Rates...22 Rate Adjustments...22 Method of Payment...22 Benefit Limitations...22 Options/Options Plus Product Material...22 Policy Booklet...23 Claim Payment...23 Agent / Broker Commissions...23 Web site...23 Contact Information...23 Appendix

5 Why a personal health plan? In promoting the Options and Options Plus plans, emphasize the importance of having a personal health plan. Why a personal health plan? Consider the following: With the cost of health care rising and budget dollars shrinking, provincially funded health programs focus mainly on services provided while in hospital or at the doctor s office. Atlantic Canadians experience rates of cancer, heart disease, asthma and diabetes among the highest in the country. The cost of treating illnesses can be staggering: * Based on drug costs for a person with a moderate to severe case of the specified illness. Depending on the severity of the illness, the costs may be higher or lower than those listed. With these facts in mind, the need for health benefit coverage becomes apparent. Apply for coverage while healthy; once sick, clients may not qualify for the coverage they need. 5

6 Options - Personal Health Plan Product Manual This manual contains a description of the principal benefits and optional modules available from the Medavie Blue Cross Personal Health Plan Options. For the most detailed descriptions of each module, please refer to the Options policy booklet. Medavie Blue Cross s Options plan includes a comprehensive base module. Optional modules can be added to the base module to build a plan that meets the client s needs. Each module is described in the following sections. Options - Benefit Overview: 1. Principal Benefits Module (Mandatory) - includes an AD&D benefit 2. Drug Module (Optional) - Available with or without a deductible 3. Dental Module (Optional) 4. Critical Care Module (Optional) - includes an AD&D benefit 5. Hospital Cash Plan Module (Optional) 6. Assured Access Module (Optional) 1. Principal Benefits Module (Mandatory) EXTENDED HEALTH BENEFITS Vision Care Medavie Blue Cross will reimburse 70 per cent up to a maximum of $150 per participant in two consecutive calendar years toward the cost of eye examinations, contact lenses, lenses and frames purchased as individual items or in combination with one another, when prescribed by a registered or licensed optometrist or ophthalmologist. Also, contact lenses prescribed for specified medical conditions are eligible for 70 per cent reimbursement, up to a maximum of $210 per participant in two consecutive calendar years. Safety glasses and sunglasses must have a prescription lens to be eligible for reimbursement. Glasses for cosmetic purposes are not eligible. A six-month waiting period applies for all vision benefits. Physiotherapy Medavie Blue Cross will reimburse 70 per cent up to a maximum of $350 per participant in a calendar year for physiotherapy. Treatment must be rendered by a licensed physiotherapist outside of government-funded hospitals, agencies or providers. The patient must have been referred by a physician. This benefit excludes health care planning assessments and is limited to a maximum of 15 treatments. 6

7 Massage Therapy, Naturopath and Acupuncture Medavie Blue Cross will reimburse $20 per visit up to a maximum of 20 visits per calendar year per practitioner by a licensed naturopath, acupuncturist or a registered massage therapist. A physician s written referral is required for massage therapy (valid for one year). Other Practitioners Medavie Blue Cross will reimburse 70 per cent up to a maximum of $210 for each practitioner per participant in a calendar year. Eligible practitioners include: a licensed qualified speech therapist, clinical psychologist, registered chiropractor, osteopath or chiropodist/podiatrist when rendered outside of government-funded hospitals, agencies or providers. Each calendar year $21 will also be allowed toward x- rays. Ambulance or Ambulance Attendant Emergency ambulance services are eligible for 70 per cent reimbursement up to a maximum of $420 in a calendar year and for travel expenses of an accompanying nurse if medically necessary and approved by Medavie Blue Cross up to a maximum of $280 in a calendar year. Private-Duty Nursing Medavie Blue Cross will reimburse 70 per cent for skilled nursing care services performed at the participant s residence when prescribed and/or recommended by the attending physician. Also, Medavie Blue Cross will reimburse 70 per cent for medically necessary services provided by personal care workers, up to four hours per day. The combined maximum amount reimbursed by Medavie Blue Cross is $3,500 per participant in two consecutive calendar years. Only services pre-approved by Medavie Blue Cross and provided by an approved Medavie Blue Cross provider will be considered for reimbursement. See policy booklet for full details, including services excluded from nursing benefit. Hearing Aids Hearing aids when prescribed by an otolaryngologist, otologist and/or a registered audiologist are eligible for 70 per cent reimbursement up to a maximum of $400 per participant every five consecutive calendar years. Batteries and hearing exams are excluded. A six-month waiting period applies to the hearing aid benefit. Diabetic Supplies Diabetic syringes, needles, swabs, and blood and urine testing supplies are eligible for 70 per cent reimbursement. Also, 70 per cent reimbursement for a blood glucose monitor up to a maximum of $70 every five consecutive calendar years. Accidental Dental Dental treatments needed because of damage to natural teeth, as a result of a direct accidental blow to the mouth, are eligible for 70 per cent reimbursement, up to a lifetime maximum of $7,000. See policy for complete benefit details. 7

8 Medical Equipment The rental of a wheelchair or hospital-type bed (including mattress and safety side-rails) when prescribed by a licensed physician is eligible for 70 per cent reimbursement. Approval for purchase may be possible, if Medavie Blue Cross determines the need for these items will be long-term. In such instances, future rental or purchases of similar equipment will be limited to once every five consecutive calendar years. Oxygen Equipment & Oxygen The rental of equipment for the administration of oxygen and charges for gaseous oxygen (excluding liquid oxygen) when prescribed by the attending physician are eligible for 70 per cent reimbursement. If the need for oxygen equipment is long-term, Medavie Blue Cross, at its discretion, may approve the purchase. In such instances, future rental or purchases of similar equipment will be limited to once every five consecutive calendar years. Prosthetic Appliances The following remedial prosthetic appliances or supplies when required due to sickness or accident occurring while this policy is in force are eligible for 70 per cent reimbursement: Artificial Limbs Breasts Hair (when due to an underlying pathology or its treatment) Eyes Crutches Canes Casts Trusses Please refer to policy booklet for dollar and frequency limits. Replacement of appliances with a lifetime maximum is only possible if required due to pathological or physiological change. Repairs and/or adjustments to these items are limited to a maximum of $105 per prosthesis in a calendar year. Orthopedic Shoes & Moulded Arch Supports Seventy per cent reimbursement for customized orthopedic shoes, shoe modification, adjustment supplies and/or molded arch supports when prescribed by an orthopedic surgeon, podiatrist, physiatrist, rheumatologist or the attending physician. The combined maximum for orthopedic shoes and moulded arch supports is $150 per participant in a calendar year. See policy booklet for complete details. 8

9 Braces and Splints Custom-made, custom-fitted or over-the-counter items, including: cervical collars, splints and braces when prescribed by a physician for musculoskeletal deficiency are eligible for 70 per cent reimbursement. Repairs and/or adjustments to these items are limited to $105 in a calendar year. Please refer to policy booklet for frequency and replacement limits. Ostomy Supplies Essential ostomy supplies, when prescribed by a physician, are eligible for 70 per cent reimbursement. See policy booklet for list of eligible items. Appliance covers and deodorants are specifically excluded. Physician s Services Out-of-Province Medavie Blue Cross will reimburse 70 per cent of the usual, customary and reasonable charges for a physician licensed to practice where the services are rendered, but within Canada, to the extent that charges are not eligible for payment from a government program, such as a reciprocal agreement under a provincial health care plan. ACCIDENTAL DEATH AND DISMEMBERMENT BENEFIT In the event of accidental death of a participant or accidental loss as described in the policy up to $10,000 will be paid for the subscriber, spouse or cohabitant and up to $5,000 for a dependent child. This benefit ends at age Drug Module (Optional) DRUG MODULE WITHOUT DEDUCTIBLE Coverage for eligible drug benefits is 70%. The maximum a participant has to pay for a prescription is 30% or $50, whichever is less. After eligible drug benefits exceed $4,500 per person in a calendar year, coverage becomes 100% for additional drug benefits in the calendar year. No overall maximum. Contraceptives are excluded, whether oral or injectable. Our Pay Direct system allows pharmacies to bill Medavie Blue Cross directly. This means subscribers pay only their portion and do not have to wait for reimbursement. DRUG MODULE WITH DEDUCTIBLE The Options drug module is also available with a calendar year deductible of $500 per person, up to a maximum of $750 for a couple or family policy. In the first year of enrolment, the deductible amount is pro-rated. Calendar year deductible ($500 per participant up to $750 for a couple or family) must be satisfied each year before benefits will be reimbursed. Coverage for eligible drug benefits is 70%. The maximum a participant has to pay for a prescription is 30% or $50, whichever is less. After drug benefits exceed $4,500 per person in a calendar year, coverage becomes 100% for additional drug benefits in the calendar year. No overall maximum. 9

10 Example I: John and Jane share a couple plan. If John has satisfied $400 of the deductible, Jane would have to satisfy the remaining $350 before she would be eligible to receive reimbursement for claims. Example II: Paul, Linda, and Sarah share a family plan. Linda has a $600 claim, Paul has a $50 claim, and Sarah has a $100 claim. Five hundred dollars of Linda s claim would go towards the deductible and the remaining $100 would be eligible for reimbursement according to the policy. Paul s $50 claim and Sarah s $100 claim would go towards the deductible. Linda is eligible for reimbursement while Paul and Sarah would still need $100 in claims collectively to satisfy the remainder of the $750 family deductible. This module allows us to provide clients who cannot afford the current Options Plus and Options plans with a lower cost alternative. This module provides an entry-level product and presents new marketing opportunities for the Options plans. This module could be targeted to past clients who did not purchase coverage due to cost, to clients who may have cancelled coverage due to cost and to clients who felt coverage was out of their reach or decided to self-insure. Rates for the new drug module are significantly lower than the existing Options Drug Module without deductible. Families who choose to add a deductible will save over $500 a year in premiums. This new Options drug module also includes a conditional carry forward provision. This provision states that if the entire deductible amount is not met during the calendar year, eligible expenses applied to the deductible amount during the last quarter of the year (October, November and December) will be carried forward and applied to the next consecutive calendar year deductible calculation. Please refer to policy booklet for complete benefit description, limitations and exclusions. 3. Dental Module (Optional) BASIC DENTAL Sixty per cent reimbursement of dentist s usual and customary fee(s) for eligible expenses incurred in Canada, up to the current Dental Society Fee Guide for general practitioners in the participant s Atlantic province of residence for the following: examinations x-rays tests & laboratory exams preventive services cleanings basic restorative services white fillings endodontic services root canal therapy basic prosthodontic services denture reline/rebase/adjustments/repairs surgical services / extractions adjunctive services. Complete or partial dentures, crowns, bridges and braces are not covered. A six-month waiting period applies for basic dental benefits. 10

11 Please refer to policy booklet for frequency limits and additional information. 4. Critical Care Module (Optional) LIFELINK CRITICAL CONDITIONS BENEFIT LifeLink is a living benefit that pays cash when you need it most. It is designed to help in the event of an unexpected, traumatic illness. If you or a dependent under your plan become ill with a critical condition meeting the degree of severity specified in the policy and survive the 30-day benefit survival period, Medavie Blue Cross will pay the applicable amount once per lifetime in its entirety: $10,000 will be paid to the subscriber, spouse or cohabitant; while a dependant child will received $5,000. The seven conditions covered under this plan are severe heart attack, life-threatening cancer, severe stroke, heart transplant, kidney failure or transplant, liver failure or transplant and lung failure or transplant. To be considered eligible, these conditions must be the result of illness or disease. No benefit will be paid for a covered condition if symptoms or sickness commenced within the participant s first 90 days of continuous coverage and result in medical treatment, consultation, care or service (including diagnostic measures) leading to the diagnosis of a covered condition. This benefit ends at age 65. Please refer to policy booklet for complete benefit description, limitations and exclusions. ACCIDENTAL DEATH & DISMEMBERMENT BENEFIT In the event of accidental death of a participant or accidental loss as described in the policy, up to $10,000 will be paid for the subscriber, spouse or cohabitant and up to $5,000 for a dependent child. This benefit ends at age Hospital Cash Plan Module (Optional) This benefit is payable for subscriber, spouse or cohabitant and dependant children and provides $100 per day for up to 100 consecutive days per calendar year when a participant is under the age of 65 and confined to an active treatment hospital as an inpatient. If a participant is 65 years of age or older, the benefit is $100 per day payable for up to 30 consecutive days of hospitalization per calendar year. When a participant is hospitalized, the benefit is calculated from the first day when due to an accident, from the fourth day when due to sickness and from the eighth day when due to pregnancy. Please refer to policy booklet for complete benefit description, limitations and exclusions. 6. Assured Access Module (Optional) The Assured Access module allows members to put their coverage on hold, should they acquire group health benefits, and to reactivate their health plan later without needing to be medically underwritten again. The Assured Access module can be purchased while applying for a personal health plan or with additional medical underwriting when acquiring group health benefits. 11

12 Participants must have been enrolled in the personal health plan with the Assured Access module for a period of six consecutive months before personal health plan benefits can be put on hold. Applications to put the personal health plan on hold must be made within 60 days of gaining group health benefits. To put the personal health plan on hold or to activate the personal health plan, contact the Medavie Blue Cross Client Services Unit toll free at

13 Options Plus - Personal Health Plan Product Manual This manual contains a description of the principal benefits and optional modules available from the Medavie Blue Cross Personal Health Plan Options Plus. For the most detailed descriptions of each module, please refer to the Options Plus policy booklet. Medavie Blue Cross s Options Plus plan is designed with a comprehensive base module. Optional modules can be added to the base module to build a plan that meets the client s needs. Each module is described in the following sections. Options Plus - Benefit Overview: 1. Principal Benefits Module (Mandatory) - includes an AD&D benefit - available with or without travel coverage 2. Drug Module (Optional) 3. Dental Module (Optional) 4. Critical Care Module (Optional) - includes AD&D and Hospital Cash benefits 5. Assured Access Module (Optional) 1. Principal Benefits Module (Mandatory) HOSPITAL BENEFITS Semi-Private Accommodation Medavie Blue Cross covers 100 per cent of the eligible expense for the difference between standard ward and semi-private room accommodation for inpatients undergoing active hospital treatment, up to a maximum of 90 days in the calendar year. If semi-private room or other preferred accommodations are unavailable, Medavie Blue Cross will provide the subscriber with a $30 per day allowance for each day hospitalized for active treatment limited to a 90-day maximum per participant in a calendar year. An eight-month waiting period applies for hospital benefits related to pregnancy. TRAVEL BENEFITS This benefit provides coverage in the event of an accident or unexpected or sudden illness occurring outside the province of residence. The plan allows unlimited trips per year up to a maximum of 30 consecutive days each. If travelling in excess of 30 days, you must purchase additional Medavie Blue Cross travel coverage for the remainder of your trip. Medavie Blue Cross will pay usual, customary and reasonable charges in excess of the amount paid by your provincial health insurance plan. This benefit is optional at age 65. In the event of an accident or sudden illness requiring treatment, participants are required to contact Medavie Blue Cross s Worldwide Assistance provider immediately. Worldwide Assistance provides emergency response and refers participants to a network of hospitals and physicians known as Preferred Provider Organizations (PPO) selected to provide health care services. Medavie Blue Cross and its Worldwide Assistance provider reserve the right to direct participants requiring medical treatment to hospitals and physicians that have been selected to provide health care services. A co-payment of $500 U.S. for inpatient hospital admission and $25 U.S. for treatment at an outpatient facility applies if a participant chooses NOT to be treated by, or transferred to, a PPO. 13

14 Worldwide Assistance medical services include confirmation of coverage, supervision of medical treatment, assistance in contacting family or business partner and help with transportation arrangements. Non-medical services include arrangements for local care of dependent children, transmission of urgent messages, assistance with lost passport or airline tickets, information on visas and vaccines and assistance with claims processing. Travel Benefits include: Hospital accommodation Diagnostic services i.e. x-rays and other medically necessary inpatient services Outpatient services Doctors, nurses, and other paramedical services Prescriptions and treatments Medical appliances such as wheelchair rental, crutches and canes Emergency dental care up to $2,000 Canadian for treatment due to direct, accidental blow to natural teeth Ambulance and air ambulance services Repatriation (transportation home for medical attention) Friend/family hospital visits Return of deceased Vehicle return services up to $1,000 Canadian Automatic extension of coverage when trip is delayed due to accident or illness Meals and accommodations allowance up to $1,500 Canadian when trip is delayed Please refer to the policy booklet for full details, limitations and exclusions EXTENDED HEALTH BENEFITS Vision Care Medavie Blue Cross will reimburse 70 per cent up to a maximum of $300 per participant in two consecutive calendar years toward the cost of eye examinations, contact lenses, lenses and frames purchased as individual items or in combination with one another, when prescribed by a registered or licensed optometrist or ophthalmologist. In addition, contact lenses prescribed for specified medical conditions are eligible for 70 per cent reimbursement, up to a maximum of $210 per participant in two consecutive calendar years. Safety glasses and sunglasses must have a prescription lens to be eligible for reimbursement. Glasses for cosmetic purposes are not eligible. A six-month waiting period applies for all vision benefits. Physiotherapy Medavie Blue Cross will reimburse 70 per cent up to a maximum of $490 per participant in a calendar year for physiotherapy. Treatment must be rendered by a licensed physiotherapist outside of government-funded hospitals, agencies or providers. The patient must have been referred by a physician. This benefit excludes health care planning assessments and is limited to a maximum of 15 treatments. 14

15 Massage Therapy, Naturopath and Acupuncture Medavie Blue Cross will reimburse $20 per visit to a licensed naturopath, acupuncturist or a registered massage therapist up to a maximum of 20 visits per calendar year per practitioner. A physician s written referral is required for massage therapy (valid for one year). Other Practitioners Medavie Blue Cross will reimburse 70 per cent up to a maximum of $300 for each practitioner per participant in a calendar year. Eligible practitioners include: a licensed qualified speech therapist, clinical psychologist, registered chiropractor, osteopath or chiropodist/podiatrist when rendered outside of government-funded hospitals, agencies or providers. Each calendar year $21 will also be allowed toward x- rays. Ambulance or Ambulance Attendant Emergency ambulance services are eligible for 70 per cent reimbursement up to a maximum of $420 in a calendar year. Travel expenses of an accompanying nurse if medically necessary and approved by Medavie Blue Cross are eligible for 70 per cent reimbursement up to a maximum of $280 in a calendar year. Private-Duty Nursing Medavie Blue Cross will reimburse 70 per cent for skilled nursing care services performed at the participant s residence when prescribed and/or recommended by the attending physician. Also, Medavie Blue Cross will reimburse 70 per cent for medically necessary services provided by personal care workers, up to four hours per day. The combined maximum amount reimbursed by Medavie Blue Cross is $5,600 per participant in two consecutive calendar years. Only services pre-approved by Medavie Blue Cross and provided by an approved Medavie Blue Cross provider will be considered for reimbursement. See policy booklet for full details, including services excluded from nursing benefit. Hearing Aids Hearing aids when prescribed by an otolaryngologist, otologist and/or a registered audiologist are eligible for 70 per cent reimbursement up to a maximum of $500 per participant every five consecutive calendar years. Batteries and hearing exams are excluded. A six-month waiting period applies to the hearing aid benefit. Diabetic Supplies Diabetic syringes, needles, swabs, and blood and urine testing supplies are eligible for 70 per cent reimbursement. Also, a blood glucose monitor is eligible for 70 per cent reimbursement up to a maximum of $70 every five consecutive calendar years. 15

16 Accidental Dental Dental treatments needed because of damage to natural teeth as a result of a direct accidental blow to the mouth are eligible for 70 per cent reimbursement up to a lifetime maximum of $7,000. See policy for complete benefit details. Medical Equipment The rental of a wheelchair or hospital-type bed (including mattress and safety side-rails) is eligible for 70 per cent reimbursement when prescribed by a licensed physician. Approval for purchase may be possible, if Medavie Blue Cross determines the need for these items will be long-term. In such instances, future rental or purchases of similar equipment will be limited to once every five consecutive calendar years. Oxygen Equipment & Oxygen The rental of equipment for the administration of oxygen and charges for gaseous oxygen (excluding liquid oxygen) are eligible for 70 per cent reimbursement when prescribed by the attending physician. If the need for oxygen equipment is long-term, Medavie Blue Cross, at its discretion, may approve the purchase. In such instances, future rental or purchases of similar equipment will be limited to once every five consecutive calendar years. Prosthetic Appliances The following remedial prosthetic appliances or supplies when required due to sickness or accident occurring while this policy is in force are eligible for 70 per cent reimbursement: Artificial Limbs Breasts Hair (when due to an underlying pathology or its treatment) Eyes Crutches Canes Casts Trusses Please refer to policy booklet for dollar and frequency limits. Replacement of appliances with a lifetime maximum is only possible if required due to pathological or physiological change. Repairs and/or adjustments to these items are limited to a maximum of $105 per prosthesis in a calendar year. Orthopedic Shoes & Moulded Arch Supports Seventy per cent reimbursement for customized orthopedic shoes, shoe modification, adjustment supplies and/or molded arch supports when prescribed by an orthopedic surgeon, podiatrist, physiatrist, rheumatologist or the attending physician. The combined maximum for orthopedic shoes and moulded arch supports is $225 per participant in a calendar year. See policy booklet for complete details. 16

17 Braces and Splints Custom-made, custom-fitted or over-the-counter items, including cervical collars, splints and braces when prescribed by a physician for musculoskeletal deficiency are eligible for 70 per cent reimbursement. Repairs and/or adjustments to these items are limited to $105 in a calendar year. Please refer to policy booklet for frequency and replacement limits. Ostomy Supplies Essential ostomy supplies when prescribed by a physician are eligible for 70 per cent reimbursement. See policy booklet for list of eligible items. Appliance covers and deodorants are specifically excluded. Physician s Services Out-of-Province Medavie Blue Cross will reimburse 70 per cent of the usual, customary and reasonable charges for a physician licensed to practice where the services are rendered, but within Canada, to the extent that charges are not eligible for payment from a government program, such as a reciprocal agreement under a provincial health care plan. ACCIDENTAL DEATH & DISMEMBERMENT BENEFIT In the event of accidental death of a participant or accidental loss as described in the policy, up to $15,000 will be paid for the subscriber, spouse or cohabitant, and up to $5,000 for dependent child. This benefit ends at age Drug Module (Optional) Coverage for eligible drug benefits is 80%. The maximum a participant has to pay for a prescription is 20% or $50, whichever is less. After drug benefits exceed $4,500 per person in a calendar year, coverage becomes 100% for additional drug benefits in the calendar year. No overall maximum. Most contraceptives are covered. Our Pay Direct system allows pharmacies to bill Medavie Blue Cross directly. This means subscribers pay only their portion and do not have to wait for reimbursement. The Options Plus plan does not offer a drug module with a deductible. 3. Dental Module (Optional) BASIC DENTAL Dentist s usual and customary fee(s) for eligible expenses incurred in Canada are eligible for 70 per cent reimbursement, up to the current Dental Society Fee Guide for general practitioners in the participant s Atlantic province of residence for the following: examinations 17

18 x-rays tests & laboratory exams preventive services cleanings basic restorative services white fillings endodontic services root canal therapy basic prosthodontic services denture reline/rebase/adjustments/repairs surgical services / extractions adjunctive services. Complete or partial dentures, crowns, bridges and braces are not covered. A six-month waiting period applies for basic dental benefits. Please refer to policy booklet for frequency limits and additional information. PERIODONTAL SERVICES BENEFIT Medavie Blue Cross will pay 50 per cent up to a maximum of $1,000 per participant, per calendar year for eligible periodontal services incurred in Canada, up to the Dental Society Fee Guide for general practitioners in the participant s Atlantic province of residence. Benefits include: non-surgical services, surgical services, adjunctive services, six additional units of scaling, root planning, periodontal appliances and periodontal re-evaluation. A 24-month waiting period applies for Periodontal Services benefits. 4. Critical Care Module (Optional) LIFELINK CRITICAL CONDITIONS BENEFIT LifeLink is a living benefit that pays cash when you need it most. It is designed to help in the event of an unexpected, traumatic illness. If you, or a dependent under your plan, become ill with a critical condition meeting the degree of severity specified in the policy and survive the 30-day benefit survival period, Medavie Blue Cross will pay the applicable amount once per lifetime in its entirety: $25,000 will be paid to the subscriber, spouse or cohabitant, while a dependant child will receive $10,000. The 18 conditions covered under this plan are Alzheimer s disease, blindness, burns, coma, deafness, heart transplant, kidney failure or transplant, life-threatening cancer, liver failure or transplant, loss of speech, lung failure or transplant, motor neuron disease, multiple sclerosis, paralysis, Parkinson s disease, and senile dementia, severe heart attack and severe stroke. To be considered eligible, these conditions must be the result of illness or disease. No benefit will be paid for a covered condition if symptoms or sickness commenced within the participant s first 90 days of continuous coverage and result in medical treatment, consultation, care or service (including diagnostic measures) leading to the diagnosis of a covered condition. This benefit ends at age 65. Please refer to policy booklet for complete benefit description, limitations and exclusions. ACCIDENTAL DEATH & DISMEMBERMENT BENEFIT In the event of accidental death of a participant or accidental loss as described in the policy up to $25,000 will be paid for the subscriber, spouse or cohabitant and up to $10,000 for a dependent child. 18

19 This benefit ends at age 65. HOSPITAL CASH PLAN BENEFIT This benefit is payable for subscriber, spouse or cohabitant and dependent children and provides $100 per day for up to 100 consecutive days per calendar year when a participant is under the age of 65 and confined to an active treatment hospital as an inpatient. If a participant is 65 years of age or older, the benefit is $100 per day payable for up to 30 consecutive days of hospitalization per calendar year. When a participant is hospitalized, the benefit is calculated from the first day when due to an accident, from the fourth day when due to sickness and from the eighth day when due to pregnancy. Please refer to policy booklet for complete benefit description, limitations and exclusions. 5. Assured Access Module (Optional) The Assured Access module allows members to put their coverage on hold, should they acquire group health benefits, and to reactivate their health plan later without needing to be medically underwritten again. The Assured Access module can be purchased while applying for a personal health plan or with additional medical underwriting when acquiring group health benefits. Participants must have been enrolled in the personal health plan with the Assured Access module for a period of six consecutive months before personal health plan benefits can be put on hold. Applications to put the personal health plan on hold must be made within 60 days of gaining group health benefits. To put the personal health plan on hold or to activate the personal health plan, contact the Medavie Blue Cross Client Services Unit toll free at Pre-Approved Life Pre-Approved Life is offered in conjunction with the Options and Options Plus personal health plans. Features of this plan include: No medical examinations or tests to complete. Qualification is simply based on answers to the medical question on the Options/Options Plus health application. Sold to individuals between the ages of 16 and 40 and guaranteed renewable until age 65. Family coverage available: $25,000 or $50,000 for policy owner, spouse or cohabitant; $5,000 or $10,000 for children. Smoker and non-smoker rates. No policy fee is required. Benefits are guaranteed payable upon death. 19

20 General Information - Options/Options Plus Personal Health Plans APPLICATION PROCEDURE All applicants must complete a medical questionnaire and qualify medically. The Options and Options Plus application has two sections: Part I requests general information on the applicant and dependents and the effective date of the policy. Please refer to the application for details. Part II requests medical information for all individuals applying for coverage. Please explain to clients the importance of making full and accurate disclosure of the matters covered in the application and that any misrepresentations or omissions give Medavie Blue Cross the right to cancel the contract of insurance and refuse coverage under the policy. At the end of Part II is the Agreement and Consent to be reviewed and signed by the applicant and spouse or cohabitant. Medavie Blue Cross performs ongoing audits that may identify cases where medical information was not completely disclosed by the subscriber or any dependents while applying for coverage under the Options/Options Plus policy. When it is determined there has been material misrepresentation on the part of the subscriber, or any dependents under the policy, the Options/Options Plus policy will be rendered null and void as of the date the policy was originally issued. The Pre-Authorized Debit (PAD) Plan Agreement section requires information about the clients bank. A void cheque also needs to be attached. PRE-EXISTING CONDITIONS These health plans are not intended to cover conditions clients already have, which we refer to as preexisting conditions. Pre-existing medical conditions will be assessed through the medical underwriting process and may result in an exclusion(s), in a substandard rating or the decline of Options/Options Plus coverage. When an exclusion is placed on a policy, the intent is to exclude all benefits and services related to a condition that existed at the time of application. If the client later requires that same benefit or service because a new condition has developed after the policy was in force, he/she would be covered. For example, if at the time of application a client has knee problems and has had physiotherapy treatments regularly for many years, physiotherapy will be excluded FOR THE KNEE(S). If after the policy is in force, the client injures his/her arm and requires physiotherapy treatments for the arm, that will be an eligible benefit. We require a note from their medical doctor indicating the condition being treated. It is important to explain to prospective clients the medical underwriting process, exclusions and substandard ratings. Once clients are sick, they may not qualify for the coverage they need. WAITING PERIODS Clients must be thoroughly informed on the waiting periods associated with certain modules and benefits. This portion of the Options/Options Plus policy can sometimes be a source of confusion for the client when making a claim (please refer to each section for more detailed information on the benefit s waiting period). The following benefits and corresponding waiting periods apply to the Options and Options Plus plans: 20

21 90 days Critical Conditions Module Six months Hearing Aids Vision Care Basic Dental Assured Access Module Eight months Semi-private hospital when relating to pregnancy 24 months Periodontal Services Benefits (Options Plus) The waiting period is considered satisfied only at the end of the applicable month. For example, for a sixmonth waiting period, it is at the end of the sixth month that the waiting period has been met. This means, services performed in the seventh month are the first eligible for payment. Often, as soon as the sixth month begins, clients will make appointments for services to be performed within the sixth month, this is too early. The six month waiting period would be over September 1 st for a client with a March 1 st effective date. Waiting periods are in place to help control premiums for our members. Without waiting periods, some clients sign up, receive thousands of dollars in planned claims and then cancel their policy. Waiting periods protect our members as their premiums fund all claims. Waiting periods can be waived for clients who previously had group coverage. The following conditions must be satisfied: Must apply within 30 days of losing group coverage. Proof (letter) of coverage and benefits for non Medavie Blue Cross groups. Eight-month waiting period for claims related to pregnancy is waived when client is coming from a Medavie Blue Cross group plan only. BENEFITS The benefits under the Options/Options Plus policies supplement, and are not intended to replace, government health care plans. Only participants eligible for benefits under government hospital and provincial health care plans are entitled to the benefits of the policy. Medavie Blue Cross will make payments for eligible benefits only in excess of the government health care allowances and only where permitted by Provincial Legislation. Medavie Blue Cross will not make payment for any health care services or supplies administered by government funded hospitals, agencies or providers, unless otherwise specified in the policy. ELIGIBILITY Only permanent residents of Atlantic Canada covered by a provincial health care plan are eligible under the policy. Children may be added to a policy without satisfying medical requirements if application is made within 31 days of birth or adoption, unless otherwise stated in the policy. Medavie Blue Cross must be notified each September of any dependents 21 years of age and over (up to their 25th birthday) who are full-time students at an accredited school, university or college. After the dependent s 21st birthday, he/she will be no longer covered under the policy unless he/she meets this requirement. 21

22 A spouse may be added to the policy without satisfying medical requirements if application is made within 31 days of marriage, unless otherwise specified in the policy. A cohabitant may be added to the policy only with evidence of insurability satisfactory to Medavie Blue Cross. RATES Medavie Blue Cross groups rates by age. The age-bands are as follows: 16-44, 45-54, and 65+. There are also separate rates for single, couple and family plans. With couple or family plans, rates are based on the oldest person covered under the policy. In lieu of a spouse, the subscriber can name a cohabitant. This cohabitant must reside at the same address, but does not have to be related. * Click HERE for Options rates Effective November 1, 2011 * Click HERE for Options Plus rates Effective November 1, 2011 =========================DISCLAIMER============================ The Options and Options Plus rates in the Appendix are only a sample and are not to be used when quoting coverage for clients. These rates will change on a regular basis. Use the most up to date Options and Options Plus rate guide for current rates. =========================================================================== Rate Adjustments Medavie Blue Cross normally adjusts rates annually, and base rates on the projected cost of benefit services for the coming year. Rates are also affected by age, so rates will be adjusted on a subscriber s anniversary date of coverage in the year the subscriber moves to a new age category, called an age band. METHOD OF PAYMENT Payment can be made by pre-authorized, automated monthly deductions from the client s chequing account. BENEFIT LIMITATIONS (please refer to the policy booklets for a complete listing of benefit limitations) The Options/Options Plus benefits do not include: Any service not listed as a benefit. Any health care services and supplies administered by government-funded hospitals, agencies or providers, unless otherwise specified in the policy. Charges in excess of those considered usual, customary and reasonable. Any claims in respect to a pre-existing condition, unless the condition is declared on the application and approved by Medavie Blue Cross (detailed information on pre-existing conditions available in Options/Options Plus policy booklet). Any claims due to war, riot or insurrection. Charges for most services or benefits received outside of Canada (except for travel benefits included in the Options Plus Principal Benefits Module). Any health care services or goods to which the participant is entitled under any Worker s Compensation statute or any other legislation OPTIONS/OPTIONS PLUS PRODUCT MATERIAL Options/Options Plus Promotional Folder No one plans to get sick General everyday health care expenses BRO-207 BRO-229 FLY

23 Application Options Policy Booklet Options Plus Policy Booklet FORM-047 BRO-010 BRO-016 POLICY BOOKLET This product manual is meant to give an overview of the Options and Options Plus personal health plans. For a comprehensive overview of plan benefits, limitations, exclusions and complete policy details, it is important that the agent/broker and client read the Options and Options Plus policy booklets thoroughly. CLAIM PAYMENT Claim payment can be made in the following ways: Drugs/Hospital/Travel: pay direct claim payment Extended Health Benefits/Hospital Cash: client submits claims to Medavie Blue Cross for reimbursement o Eligible claims can be reimbursed on the spot at one of nine Quick Pay locations or clients can mail in claims Web initiatives allow Dental, Vision Care Providers, Physiotherapists and Chiropractors to bill directly. AGENT / BROKER COMMISSIONS Active Agents/Brokers Non Active Agents/Brokers 1 st Year Subsequent Renewals 25% 10% 15% 0% Sales also available for all agents. WEB SITE Medavie Blue Cross s Web site offers current and potential clients easy access to information about our products and services. Visit us at CONTACT INFORMATION Product Information & Inquiries: Sales Support Team: Serge Leblanc, Manager Individual Sales (NB/PEI): Lisa Smith, Manager Individual Sales (NS/NL): Agent Micro site Agent Updates 23

24 Appendix (**These rates are not to be used when quoting coverage. For illustration purposes only**) OPTIONS - Rates Return to RATES section of Agent Training Manual (**These rates are not to be used when quoting coverage to potential clients**) 24

25 OPTIONS PLUS - Rates Return to RATES section of Agent Training Manual 25