Supplementary Health Care Plan for CBC/Radio-Canada pensioners outside the Atlantic provinces

Transcription

1 Supplementary Health Care Plan for CBC/Radio-Canada pensioners outside the Atlantic provinces January 2013

2 Table of contents About Great-West Life... 1 Eligibility... 1 Pensioners... 1 Surviving spouses... 1 Who qualifies as an eligible family member?... 1 Starting, opting out or changing coverage... 2 Dependent confirmation if you have family coverage... 3 Cost... 3 Coverage... 4 Hospitalization... 4 Drugs... 4 Medical services and supplies... 6 Exclusions and limitations... 8 Claims... 9 Drugs and medical supplies and services Special authorization Hospital coverage Out-of-province hospital and medical expenses Reimbursement under more than one plan In case of death When coverage ends January 2013

3 The Supplementary Health Care Plan (SHCP) helps with medical expenses, supplementing provincial plan coverage. About Great-West Life Great-West Life Assurance Company provides administrative services only for the SHCP, under contract # Your coverage includes a pay-direct drug card. With your drug card, eligible drug expenses are reimbursed automatically when you fill your prescription at the pharmacy. For claims, coverage and drug card inquiries, contact Great-West Life at or visit Eligibility Pensioners You, your spouse, and your children are eligible for SHCP coverage when you retire with an immediate pension and you and your dependents all reside in Canada. You, your spouse, and your children are eligible for SHCP coverage when you begin receiving a deferred pension, as long as you apply no more than 60 days after your pension begins. You will have to prove that you were covered under another employer's group health care plan between the time you left CBC/Radio-Canada and the date you apply for SHCP coverage. Surviving spouses If you have family coverage under the SHCP and your spouse becomes eligible for a CBC/Radio-Canada survivor pension, your spouse and eligible children may maintain their coverage after your death. If your spouse is not eligible for a CBC/Radio-Canada survivor pension, only your spouse may continue to be covered after your death and any children would not be eligible for coverage. However, your spouse may not cover a new spouse. Who qualifies as an eligible family member? Your spouse is: the person to whom you are legally married, or the person who has been represented as your spouse and living with you for at least one year. January

4 A former spouse may be covered under the plan if required by court order; however, only one spouse is eligible for coverage at any one time. Your children are: Unmarried children (including a stepchild, an adopted child, a foster child, a child for whom you or your spouse has been appointed legal guardian, or a child born to your unmarried minor female dependent): under age 21 and working less than 30 hours a week, under age 25 (under age 26, residing in Québec, only for health coverage of drugs eligible under the provincial drug plan) if full-time students studying 15 or more hours a week, or disabled children, as long as they depend totally on you for support and were covered by this plan immediately before their 21st birthday. Starting, opting out or changing coverage When you retire, you can apply for coverage under the Retiree Supplementary Health Care Plan (SHCP), no more than 60 days after your retirement date. Please note that the Régie de l assurance maladie du Québec (RAMQ) requires that all Quebec residents under the age of 65 be enrolled under a Health Care Plan offered by an employer. If you retire before the age of 65, you will automatically be enrolled for single coverage. If you retire with a deferred pension, to be eligible for coverage under the SHCP, you will have to provide proof that you and your eligible dependents have been covered under a Group Health Care Plan since leaving CBC/Radio-Canada. You can opt out of the SHCP at anytime, except in Québec where the participation is mandatory to age 65. You can join the SHCP if you opted out because you were covered under another employer's group health care plan (your own or your spouse's), and you lose that coverage. You can join no more than 60 days after that coverage ends and you will have to prove that you were covered under another employer's group health care plan between the time you opted out and the date you apply for SHCP coverage. If you have been covered while outside Canada by another employer s group health care plan and that coverage ends upon your return to Canada, you may rejoin the CBC/Radio-Canada s SHCP for retirees only if you meet the criteria mentioned above. If you do rejoin the SHCP, the services and supplies normally eligible for reimbursement by the provincial health care plan will not be covered by the SHCP during the provincial health care plan s waiting period. If you have single coverage, you can only change to family coverage after certain life changes, no more than 60 days after the life change. These life changes would make you eligible to change coverage: marrying or having your common-law spouse become eligible, birth, adoption, or legal guardianship of a child, and January

5 loss of your spouse's coverage under another employer's group plan. You will have to prove that your spouse was covered under another employer s group health care plan between the time you changed to single coverage and the date your spouse s coverage ended. You will need to complete the Supplementary Health Care Plan Application/Modification/Dependent Information form, which can be found on the CBC/Radio- Canada Pension Administration Centre (PAC) website, to register your dependent(s) or make changes to dependent information. Note that Great-West Life will only process claims for your eligible dependents (for drug and non-drug expenses) if they have been registered with PAC. Dependent confirmation if you have family coverage Pensioners with family coverage need to provide the CBC/Radio-Canada Pension Administration Centre (PAC) with current information about their eligible dependents for dependent claims to be processed. Send PAC a completed Supplementary Health Care Plan Application/Modification/Dependent Information form, available on the PAC website or by contacting PAC by phone, whenever you need to: add a dependent for coverage (add a spouse or child), terminate coverage for a dependent (a spouse or a child who no longer meets the definition of eligible dependent), certify a child as a student at age 21; PAC will contact you annually to re-certify the child as a student, change information regarding your spouse's health coverage with another plan, or initiate the process to certify a child as disabled, Cost You pay the cost of the plan, deducted from your pension each month. The CBC/Radio-Canada Pension Administration Centre will notify you of the amount of your premiums. If the premium you owe for coverage is higher than the amount of your pension, the CBC/Radio- Canada Pension Administration Centre will send you a bill for the remaining premium once a year. January

6 Coverage Drug expenses The plan pays 80% of the first $750 of eligible drug expenses for each covered person in each benefit year Then 100% of eligible drug expenses for the remainder of that benefit year. All other eligible expenses The plan pays 80% of the first $500 of eligible non-drug expenses for each covered person in each benefit year Then 100% of eligible non-drug expenses for the remainder of that benefit year. Each benefit year runs from June 1 to May 31. The SHCP does not cover expenses incurred outside Canada or expenses that are eligible for reimbursement under a government assistance program or provincial health plan. Be sure to ask your health care provider whether such a program exists in your province. The SHCP covers eligible expenses incurred in Canada while temporarily out-of-province on business, or vacation or for furthering education, which were incurred as a result of an emergency or a sudden unexpected illness, provided these expenses would have been covered by your provincial health plan had they been incurred in your province of residence, The SHCP also covers eligible expenses incurred in Canada, outside your province of residence, for reasonable and customary treatment which is not readily available in your province of residence which would have been paid by the provincial health plan had the treatment been rendered in your province of residence. Hospitalization Hospitalization and related services and supplies, above provincial health care coverage, including care in a convalescent hospital, to a maximum of 120 days in any one benefit year, provided that the hospitalization is recommended by the doctor and follows a hospitalization of at least three days in an active treatment hospital for the same condition: the difference between charges for standard ward and semi-private accommodation, and out-patient supplies and services not covered by the provincial plan. Drugs Reimbursement of prescription drugs will be based on the cost of the lowest-cost generic alternative of the prescribed drug (if there is one) unless there is a medical reason that would prevent the use of a generic drug as attested by the patient s doctor. If there is a medical reason why the patient cannot take the generic equivalent of the brandname drug, the patient and the patient s doctor must complete and send to Great-West Life the Request for Brand Name Drug Coverage form. Great-West Life will assess the request and send a letter indicating if the request for brand-name drug coverage has been approved. You January

7 can obtain the form from the Great-West Life website or by contacting Great-West Life by phone. If there is no medical reason preventing you from using the generic equivalent of the brandname drug prescribed, but you choose to ask for the brand-name drug, the SHCP will pay the cost of the lowest-cost generic alternative and your share of the cost will increase. Drugs medication that legally requires a physician's (M.D.) prescription and is dispensed by a licensed pharmacist, or other person entitled by law to dispense it, including insulin and insulin-related supplies (syringes, needles, test strips and lancets), injectable drugs, and limited over-the-counter medication judged by Great-West Life to be life-sustaining, subject to the deductible indicated below. A maximum of $15 will be reimbursed, also subject to the deductible, for each drug or injection provided in a clinic or doctor's office. Deductible for Ontario residents up to age 65 for Ontario residents age 65 and over for Québec residents up to age 65 For Québec residents age 65 and over the dispensing fee (co-pay) charged by the pharmacist the dispensing fee charged by the pharmacist and the provincial deductible $7.50 for each prescription The $7.50 deductible does not apply to drugs eligible under the provincial drug plan, which pays benefits first If you are under age 65 and your spouse is aged 65 or more, he or she will have to enroll in the RAMQ Prescription Drug Insurance Public Plan. You may submit your spouse s drug receipts for any amount not covered by the RAMQ plan to Great West Life. On your 65th birthday, you will be automatically enrolled in the RAMQ Prescription Drug Insurance Public Plan. If you have a spouse who is insured under the SHCP who has not yet reached age 65, you will have to enroll them in the RAMQ Plan. All drugs will therefore be covered by RAMQ and you may submit your drug receipts for any amount not covered by the RAMQ plan to Great West Life. All other benefits under the SHCP remain unchanged. If, upon your death, your spouse is a Québec resident, your spouse and any eligible children must apply for drug coverage under the Régie de l'assurance maladie, even if your spouse is under age 65. January

8 Drugs for residents of provinces and territories other than Ontario and Québec the amount paid by any provincial plan This plan is integrated with any applicable government benefit program (for example the reimbursement for eligible drug expenses may be coordinated with the provincial drug plan when you reach 65). Medical services and supplies It is a good idea to call Great-West Life before making any large expenditures on supplies and services you believe are covered by the plan (for example, private duty nursing, nursing homes, etc.). Great-West Life will let you know whether the expense is eligible for reimbursement and how much of the cost the plan will reimburse. Before you call, be sure to have all the details possible about the expense at hand. Ambulance Blood products Chronic care Dental treatment licensed ground or air ambulance to the nearest centre where essential treatment is available blood transfusions and other blood products confinement in a hospital or qualified nursing home, to a maximum of $20 a day: for a chronically ill person in relatively stable condition who has reached the limits of recovery, and involving the need for daily professional nursing care and medical supervision for a chronically ill person for a short period (e.g. two weeks) as respite care, to allow that person s caregiver some time to rest, provided that the caregiver lives with the patient and is not paid for the services Combined reimbursement for chronic care and out-of-hospital private-duty nursing is $15,000 for each covered person in any one benefit year, in addition to the limits indicated within each benefit description treatment required as a result of an accidental injury to natural or artificial teeth, provided that treatment is received outside hospital, no more than six months after the accident January

9 Hospital and medical expenses outside the province of residence Hearing aids Medical supplies Orthotics Oxygen Paramedical services (no doctor's prescription needed) eligible expenses incurred while in another Canadian province, provided that some portion of the expense is payable by the provincial plan or would be eligible under the provincial plan if incurred in the province of residence, subject to Great-West Life's evaluation, for: emergency hospitalization and medical services while temporarily out-of-province on vacation or for furthering education and hospital charges and medical expenses for treatment not readily available in the patient's province of residence hearing aids prescribed by an ear, nose, and throat specialist, to a maximum of $250 for each covered person every 60 consecutive months rental or, at Great-West Life's option, purchase of a wheelchair, hospital bed, iron lung, or positive-pressure breathing machine (including maintenance and replacement), once any government assistance plan maximums have been reached splints, trusses, braces with rigid supports (excluding lumbar supports), crutches, or casts, orthopedic shoes, prescribed by a qualified practitioner, designed and constructed specially for the covered person, to a maximum of one pair in each 12-consecutive month period for an adult and reasonable and customary charges for children under age 18 Orthopedic shoes purchased to accommodate an orthotic are not covered custom-made orthotics, provided that the cost is, in the opinion of Great-West Life, in accordance with the fee schedule in the area, and if not available, representative fees and prices in the area in which the charge is incurred including cost associated with its administration services of: licensed chiropractors licensed osteopaths licensed podiatrists or chiropodists licensed naturopaths and qualified acupuncturists once any provincial plan maximum has been reached January

10 Private-duty nursing Prosthetic appliances/supplies Psychology services Radium services, outside hospital, of a graduate registered nurse or registered nursing assistant, or licensed practical nurse, not related to the patient, provided the care is not primarily custodial and cannot be performed by someone less qualified Combined reimbursement for chronic care and out-of-hospital private-duty nursing is $15,000 for each covered person in any one benefit year, in addition to the limits indicated within each benefit description artificial limbs or eyes and other prosthetic devices required after surgery, including repair and replacement (excluding myoelectrical limbs), once any government assistance plan maximums have been reached out-of-hospital treatment by a registered psychologist (a doctor's prescription is required annually or if treatment is interrupted by six or more months) treatment by X-ray, radium, and radioactive isotopes Therapeutic services services of a: licensed physiotherapist not related to the patient (including a physical rehabilitation therapist for Québec residents) qualified massage therapist A doctor's prescription is required annually or if treatment is interrupted by six or more months Exclusions and limitations SHCP benefits are not paid when the patient is not under the continuing care of a physician (M.D.), or supplies and services: received before the person was covered by this plan, covered by any government plan, including provincial health care, workers' compensation or provincial automobile insurance, or for which a government plan prohibits payment, generally provided without cost, or that the person would not have had to pay in the absence of this insurance, provided by a government hospital, unless you are required to pay for such services, provided by CBC/Radio-Canada, a mutual benefit association, or any employee group, cosmetic surgery or treatment, unless such surgery or treatment is for accidental injuries and commenced, or reported and approved for payment, within 180 days of an accident, or as soon as feasible following the accident, depending upon the medical condition of the patient, related to suicide or attempted suicide or self-inflicted illness or injury, whether the person was sane or insane, or in connection with an injury or disease resulting from voluntary participation in a war or any act of war, civil disorder, riot or insurrection. January

11 In addition, no benefits are paid for: any injury sustained as a result of or in the course of any employment other than with CBC/Radio-Canada, a disability that the covered person chooses not to have treated by a doctor, treatments received while in the services of any armed forces, hospital services primarily provided for chronic or custodial care, unless specifically covered as an eligible expense, hospitalization in a detoxification centre for treatment of alcoholism or drug abuse, cosmetic surgery or treatment, unless such surgery or treatment is for accidental injuries and commenced within 180 days of an accident, or as soon as feasible following the accident, depending upon the medical condition of the patient, doctors' mileage or travel time, transportation costs, or consultations by telephone or other means, pregnancy tests or routine medical checkups, dental expenses, unless specifically covered as an eligible expense, hearing or vision tests, eyeglass frames or lenses, or contact lenses diabetic equipment (such as blood glucose monitoring machines, external insulin infusion pumps and needleless insulin jet injectors), and supplies for diabetic equipment (other than lancets, test strips and syringes), missed appointments, completion of forms, or medical examinations for the use of a third party, medication prescribed or dispensed without respecting federal or provincial regulations, or services performed by unqualified practitioners, delivery charges or your mileage/travel expenses for treatment, vaccines and immunization products, expenses incurred outside Canada, or drugs for erectile dysfunction. Claims For all expenses other than prescription drugs and the eligible diabetic supplies described above, submit a paper claim to Great-West Life or an e-claim via GroupNet for Plan Members on the Great-West Life website. You can print the form on the Great-West Life member website, GroupNet for Plan Members, or contact Great-West Life by phone to have one mailed to you.to make a claim for prescription drugs, please use your pay-direct drug card. Submit claims no more than 90 days after the date of the service or purchase, or as soon as you can. The plan will not pay claims submitted more than 15 months after the expense is incurred. Make sure to write your CBC ID number on every claim form. Also, you must sign the form, even if the claim is for a family member. January

12 Drugs and medical supplies and services Using your pay-direct drug card, you may obtain prescription drugs from any participating pharmacy by showing your card to the pharmacist. Great-West Life will reimburse eligible expenses to the pharmacist directly and you only pay your share of the cost of each prescription. If you purchase prescription drugs without using your pay-direct drug card, or obtain services or supplies provided on a reimbursement basis, accumulate a reasonable number of medical expense receipts, then send original receipts with a completed claim form to Great-West Life (if the claim is for coordination of benefits, when another plan pays the expenses first, photocopies of receipts are acceptable). Receipts must show: patient's name, date of the service or treatment, itemization of the charges, and Drug Identification Number (DIN), for drug expenses. If you don t use your drug card when purchasing a prescription, the pharmacist may charge you more than the established price and you may end up paying more out-of-pocket. Special authorization You may have to obtain special authorization to incur certain types of treatment if, in Great-West Life's opinion, the proposed treatment needs to be explained. This is not designed to dictate your choice of treatment, but rather to indicate to you ahead of time what the plan will pay for. You must submit a doctor's written prescription for massage therapy, physiotherapy and psychologist's services. If you don't, Great-West Life will hold your claim and contact you to provide the prescription before the claim is paid. You will need a renewal of your prescription annually when treatment is ongoing and if treatment is interrupted for six months or more. Great-West Life may also need additional information from your doctor before certain prescriptions can be paid. These drugs are listed on the Great-West Life website, GroupNet for Plan Members, or you can contact Great-West Life for the most up-to-date listing. Hospital coverage If you are in a semi-private room at your own request, give the admitting clerk your plan and ID numbers. When a doctor recommends that you need semi-private or private accommodation, the hospital pays. Generally, hospitals bill the plan directly. If they do not, send a completed claim form with the hospital's invoice to the insurer, who will pay the hospital directly. January

13 Out-of-province hospital and medical expenses For hospital and medical expenses outside your province of residence but in Canada, your doctor should contact the provincial plan to ensure that the province will cover the procedure (or would have covered it had the expense been incurred in the province of residence), then submit a treatment plan to Great-West Life for assessment. When paying expenses outside your province of residence, get detailed receipts. Submit to Great-West Life, who will coordinate payment with the provincial plan. Great-West will pay all eligible claims, including the provincial plan portion. The provincial plan will then reimburse Great-West Life for its share. Do not delay, however, because provincial plans have very strict time limits. If claims are late, your claim will not be paid by the province or Great-West Life. If you prefer, submit one set of receipts to your provincial plan and keep photocopies. Once the province pays, submit remaining eligible expenses to Great-West Life with a completed claim form, provincial statement of payment, and duplicate receipts. Reimbursement under more than one plan If you and your spouse are covered by more than one health care plan, you can claim benefits under both plans, and may receive reimbursement of up to 100% of your eligible expenses. Here's how you coordinate benefits. For expenses incurred by You Your spouse Your dependent children Submit your claim to... This plan Then, to your spouse's plan, if a balance remains Your spouse's plan Then, to this plan, if a balance remains The plan of the parent whose birthday falls earlier in the year Then, to the plan of the other parent, if a balance remains If you are separated or divorced with custody of your covered children, different rules apply. Contact Great-West Life for details. January

14 In case of death Your spouse must contact the CBC/Radio-Canada Pension Administration Centre as soon as possible after your death. The Centre will send a package containing all the information necessary for your spouse to decide whether or not to continue coverage. When coverage ends Your coverage ends (or changes, in the case of a change from family to single coverage) on the first day of the month after: the CBC/Radio-Canada Pension Administration Centre receives your written request to terminate or change coverage, or the date of your death. Coverage for your spouse and children ends at the same time or earlier, if they no longer qualify under the plan's definition of eligibility. If you, your spouse or one of your children is totally disabled and under doctor's care when coverage ends, please contact Great-West Life for information regarding the extension of benefits. This booklet summarizes the main provisions of the Supplementary Health Care Plan in effect as of January Actual benefits will be determined by the terms of the group insurance contract with Great-West Life, which will govern in case of any discrepancy. For additional information, contact Great-West Life. January