Health Care and Dental Insurance Plans

Transcription

1 Health Care and Dental Insurance lans

2 TWO OTIONS ARE AVAILABLE UNDER THE EXTENDED HEALTH CARE LAN* OTION 1 : FULL LAN Extended Health coverage with rescription Drugs, emergency services outside the province of residence and Emergency Travel Assistance. OTION 2 : BASIC LAN rescription Drugs, emergency services outside the province of residence and Emergency Travel Assistance. Deductibles $250 per policy year (March 1 st to February 28 th ). No deductible applies to hospitalisation, emergency services outside the province of residence and Emergency Travel Assistance. $100 per policy year (March 1 st to February 28 th ). No deductible applies to emergency services outside the province of residence and Emergency Travel Assistance. Reimbursement 80% of all eligible expenses will be reimbursed once the deductible has been satisfied. 100% of eligible expenses for hospitalisation, emergency services outside the province of residence and Emergency Travel Assistance. 70% of all eligible expenses will be reimbursed once the deductible has been satisfied. 100% of eligible expenses for emergency services outside the province of residence and Emergency Travel Assistance. Eligibility To apply for coverage you must: be a member in good standing of the Quebec Medical Association (QMA); be under age 65; and reside and practice medicine in the province of Québec at least 20 hours per week; and resent satisfactory proof of insurability. To apply for coverage you must: be a member in good standing of the Quebec Medical Association (QMA); be under age 65; and reside and practice medicine in the province of Québec at least 20 hours per week. * This document is not an insurance contract. Coverage is subject to the limits, terms and conditions of the policy. age 2

3 RESCRITION DRUGS Covered expenses under options 1 and 2 Charges for the following drugs and supplies that are prescribed in writing by a physician, other than the insured member, or a dentist and are obtained from a pharmacist except in areas where a pharmacist is not available. Drugs covered under this plan must have a Drug Identification Number (DIN) in order to be eligible. Drugs that legally require a prescription; Life-sustaining drugs that may not legally require a prescription; Injectable drugs and vitamins; Compounded preparations, provided that the principal active ingredient is an eligible expense ans has a DIN; Diabetic supplies; Drugs for the treatment of infertility, up to a lifetime maximum of $2,400 for each insured; Vaccines; Intrauterine devices (IUDs) and diaphragms; Varicose vein injections. ayments for any single purchase are limited to quantities that can reasonably be used in a 34 day period or, in the case of the certain maintenance drugs, in a 100 day period as ordered by a physician. age 3

4 The following are not covered under this plan, even when prescribed: Infant formulas (milk and milk substitutes), minerals, proteins, vitamins and collagen treatments; The cost of giving injections, serums and vaccines; Treatments for weight loss, including drugs, proteins and food or dietary supplements; Hair growth stimulants; roducts to help you quit smoking, other than those that must be covered in accordance with the requirements under the Québec drug insurance plan; Drugs for the treatment of sexual dysfunction; Drugs that are used for cosmetic purposes; Natural health products, whether or not they have a Natural roduct Number (NN); Drugs and treatments, and any services and supplies relating to the administration of the drug and treatment, administered in a hospital, on an in-patient or out-patient basis, or in a government-funded clinic or treatment facility. ELIGIBLE EXENSES OUTSIDE THE ROVINCE OF RESIDENCE AND EMERGENCY TRAVEL ASSISTANCE Covered expenses under options 1 and 2 Expenses occurred outside the province or country of residence Emergency and referred services. All covered expenses in excess of those reimbursed by the provincial medical plan for emergency services which occur during: Within the first 90 days of leaving the province of residence, subject to a maximum of $1,000,000 per insured, per occurrence; Within the first 30 days of leaving the province of residence, subject to a lifetime maximum of $500,000 when the insured is 71 years of age or over. age 4

5 EXENSES COVERED UNDER THE EXTENDED HEALTH CARE LAN Covered expenses under option 1 hospital: changes for a private room (maximum of 60 days) then semi-private room. As of age 71, semi-private room only; convalescence hospital: charges for room and board, if admitted within 24 days following a period as an in-patient in a hospital. Benefit is reduced by any amount payable under any provincial or federal plan. Maximum period of 120 days for any one disability, maximum of $10 per day; nursing care: up to a maximum of $5,000 in any three-year period (not covered during hospitalization). As of age 71, lifetime maximum of $15,000; paramedical services*: up to $40 per visit, subject to an overall combined maximum of $800 per insured, per policy year, for all practitioners; physiotherapists: up to $75 per visit, subject to a maximum of $1,000 per policy year, per insured; psychologist: up to $75 per visit, subject to a maximum of $1,000 per policy year, per insured. This service must be prescribed by a doctor; hearing aids: cost, installation and repair up to a maximum of $300 in any consecutive fiveyear policy period; ambulance: service to the nearest hospital, from one hospital to another and from the hospital to your residence; outpatient services: expenses for hospital services and supply that are not covered by the public hospitalization insurance plan. aramedical Services include services from acupuncturists, audiologists, chiropractors, homeopaths, naturopaths, osteopaths, podiatrists and speech therapists as well as the services from massotherapists when prescribed by a doctor other than the insured member. EQUIMENT AND OTHER SERVICES COVERED UNDER THE EXTENDED HEALTH CARE ROGRAM Covered expenses under option 1 Diagnostic tests, laboratory tests, radium treatments and x-ray examinations, subject to a maximum of $1,000 per insured, per policy year; CAT scan or magnetic resonance imaging (MRI), subject to a maximum of 500 $ per insured, per policy year; urchase of braces, crutches, canes, walkers, and artificial limbs or eyes, prosthetic devices, mastectomy brassieres (maximum 2 per policy year) and surgical stockings (maximum 2 pairs per policy year); Rental of a standard wheelchair, hospital-type bed or other durable medical equipment ($4,000 lifetime maximum on electric wheelchair); Oxygen and blood serum; age 5

6 Covered expenses under option 1 (continued) Custom made orthopaedic shoes, including modifications to orthopaedic shoes, prescribed by a doctor other than the insured member to a maximum of $400 per insured, per policy year; Orthotics (arch support inserts) to a lifetime maximum of $200 per person; Needles and syringes for diabetics; Replacement or repair of natural teeth required as a result of an accidental injury sustained while the person is insured, to a maximum of $1,000 per dental injury, per person,; Cosmetic surgery necessary to repair disfigurement due to an accident sustained while insured to a maximum of $5,000 per person, per accident; Wigs required as a result of chemotherapy to a lifetime maximum of $500 per person; Colostomy or ileostomy supplies. DEENDENT COVERAGE You can apply to cover your spouse and dependent children. If you are under age 65, your Spouse and Dependent Child must be covered through this program or another private insurance plan for rescription Drug coverage. An eligible spouse is your spouse by marriage or under any other formal union recognized by law, or a person of the opposite sex or of the same sex with whom you have cohabited for at least 12 months, and who has been publicly represented as your spouse. There is no minimum cohabitation period for common-law spouses if a child is born out of your relationship. Dependent child is an unmarried child, stepchild or legally adopted child of either you or your spouse, under the age of 21 (age 26 if a full-time student in an accredited institution of learning) and entirely dependent on you for support, or to any age if incapable of self support because of a physical or mental disability. Survivor s benefits In the event of your death while insured for Dependent Health Care Benefits, the benefits will be continued in force without premium payments for up to 12 months but not beyond the earliest of the following circumstances: When similar coverage is obtained elsewhere; Upon re-marriage of your Spouse; When your dependents cease to qualify as eligible dependents; or Termination of the policy. age 6

7 OUT-OF-OCKET MAXIMUM Expenses incurred for prescription drugs listed in the Régie de l assurance maladie du Québec (RAMQ) drug formulary and not reimbursed under this plan as a result of the application of the deductible or the reimbursement level are limited in each calendar year to the yearly maximum contribution set by the RAMQ plan. There is an out-of-pocket maximum for you, and another one for your spouse. Any drug expenses incurred for your children are part of the out-pocket maximum of the member. CO-ORDINATION OF BENEFITS If you or your dependents are covered for Extended Health under this plan and another plan, these benefits will be coordinated with the other plan following insurance industry standards. These standards determine which plan you should claim first. We invite you to contact one of our specialists, who will design a customized protection plan sure to meet your needs. age 7

8 TWO OTIONS ARE AVAILABLE UNDER THE DENTAL CARE LAN OTION 1 : BASIC LAN OTION 2 : FULL LAN Deductibles There are no deductibles. ercentage of paid expenses 80% of eligible expenses related to basic services. 80% of eligible expenses related to basic, endodontic, periodontal and surgical services; 50% of eligible expenses related to major services and orthodontic services for dependents under age 19. Annual Maximum Benefit $500 per insured for the first policy year (March1 st to February 28 th ); $1,500 per insured for each subsequent policy year. $500 per insured for the first policy year (March1 st to February 28 th ); $2,500 per insured for each subsequent policy year; $1,000 lifetime maximum per dependent child for orthodontic services. Reimbursement of dental expenses The Québec Dental Association s current fee guide is used as the basis for reimbursement for dental services under both plan options. Eligibility To apply for coverage, you must: To apply for coverage, you must: be a member in good standing of the QMA; be under age 65; reside and practice medicine in the province of Québec at least 20 hours per week; be covered under Option 1 (Full plan) or Option 2 (Basic plan) of the QMA Health Care Insurance plan. be a member in good standing of the QMA; be under age 65; reside and practice medicine in the province of Québec at least 20 hours per week; be covered under the Option 1 (Full plan) of the QMA Health Care Insurance plan. age 8

9 COVERED EXENSES UNDER OTIONS 1 AND 2 (Subject to the conditions, limitations, exclusions and maximums indicated in the contract) Basic Services DIAGNOSTIC SURGICAL Routine examinations and diagnosis; X-rays; Consultations; Laboratory procedures. REVENTATIVE Oral hygiene instruction; Scaling and polishing; Topical fluoride treatment; it and fissure sealants (for children under age 19); Space maintainers (for children under age 19). RESTORATIVE Minor surgical procedures; Complicated extractions. REMOVABLE - ROSTHODONTICS Repair; Relining; Rebasing. Fillings; Retentive pins. COVERED EXENSES UNDER OTION 2 ONLY (Subject to the conditions, limitations, exclusions and maximums indicated in the contract) Endodontic, eriodontal and Surgical Services: ENDODONTIC ulp capping and pulpotomy; Root canal therapy; apexification; eriapical services; Gingival surgery, alveolectomy, hemisection; Intentional removal, filling and reimplantation; Emergency procedures. ERIODONTAL Non-surgical treatment of gum disorder; Surgical services and post-surgical treatment; Occlusal adjustments; rovisional splinting; Scaling and root planning; Appliances, excluding athletic mouth guards; Maintenance, adjustment and repairs to appliances; SURGICAL Surgical exposure of teeth; Removal of tumours, cysts, residual roots, foreign bodies from the mouth; Alveoloplasty, gingivoplasty, stomatoplasty and osteoplasty; Frenectomy; Miscellaneous surgical and post-surgical services, including sedation; Fractures, including assisting a surgeon at fracture reduction; Repair of soft tissue lacerations; General anaesthesia and sedation in connection with the above procedures. age 9

10 SERVICES COVERED UNDER OTION 2 ONLY (Subject to the conditions, limitations, exclusions and maximums indicated in the contract) Major Services REMOVABLE ROSTHODONTIC SERVICES Initial provision of full or partial removable prosthodontics if necessary due to the extraction of one or more natural teeth while the insured person s dental coverage is in force; Replacement of, or addition to, existing removable prosthodontics. SINGLE RESTORATIONS Onlays, in-lays and gold-foil restorations; Retentive pins, limited to 3 pins per tooth; posts and cores; Removal, repair, recementation of crowns; Crowns; Replacement of crowns. FIXED BRIDGES Evaluation, X-rays; Retainer onlays; abutment crowns and pontics; Retentive pins, posts and cores, copings; Removal, repair, recementation of existing bridgework; rovisional restoration; Initial provision of fixed bridgework if necessary due to the extraction of one or more natural teeth while your dental coverage is in force; Removal and replacement of fixed bridgework. CAST METAL OST AND CORE Limited to teeth that have had root canal therapy; Maximum of one post and core per tooth. Orthodontic Services ORTHODONTIC For dependent children only, provided treatment commences prior to reaching age 19. CO-ORDINATION OF BENEFITS If you or your dependents are covered for Dental Care under this plan and another plan, these benefits will be coordinated with the other plan following insurance industry standards. These standards determine which plan you should claim from first. re-dermination of benefits If changes for any care, services or supplies are expected to exceed $500, the company recommends that a detailed treatment plan be submitted before expenses are incurred. age 10

11 DEENDENT COVERAGE You can apply to cover your spouse and dependent children if you are under age 65. An eligible spouse is your spouse by marriage or under any other formal union recognized by law, or a person of the opposite sex or same sex with whom you have cohabited for at least 12 months, and who has been publicly represented as your spouse. There is no minimum cohabitation period for common-law spouses if a child is born out of your relationship. Dependent child is an unmarried child, stepchild or legally adopted child of either you or your spouse, under the age of 21 (age 26 if a full-time student in an accredited institution of learning) and entirely dependent on you for support, or to any age if incapable of self support because of a physical or mental disability. Survivor s benefit In the event of your death while insured for Dependent Dental Care Benefits, the benefits will be continued in force without premium payments for up to 12 months but not beyond the earliest of the following circumstances: When similar coverage is obtained elsewhere; Upon re-marriage of your Spouse; When your dependents cease to qualify as eligible dependent; or Termination of the policy. Warning If you terminate your Dental Care coverage, you will not be eligible to re-enter the plan. We invite you to contact one of our specialists, who will design a customized protection plan sure to meet your needs. age 11

12 For further information, please contact an MD Financial Management Specialist: Toll free : Quebec Region : valerie.linteau@cma.ca Montreal Region : elina.pacu@cma.ca This brochure is designed to outline the benefits for which you are eligible and does not confer any contractual or other rights. All rights with respect to benefits of a member will be governed by the Master olicy issued by Sun Life Assurance Company of Canada. February 2015