A d d i t i o n a l i n f o r m a t i o n t o t h e b o o k l e t d a t e d J a n u a r y

Transcription

1 A D D I T I O N A L P L A N 1 D E N T A L C A R E J O F F E R E D T O M E M B E R S O F U N I O N S A F F I L I A T E D T O T H E C E N T R A L E D E S S Y N D I C A T S D U Q U É B E C A d d i t i o n a l i n f o r m a t i o n t o t h e b o o k l e t d a t e d J a n u a r y M A R C H P l e a s e k e e p t h i s b o o k l e t f o r f u t u r e r e f e r e n c e

2 S S Q T o w e r L a u r i e r B o u l e v a r d P. O. B o x S a i n t e - F o y, Q u e b e c G 1 V 4 H 6 I n f o r m a t i o n - D e n t a l C a r e Q u e b e c a r e a : ( ) E l s e w h e r e i n Q u e b e c : BV4261A ( )

3 This plan is part of the contract of the CSQ and is governed by the terms and conditions mentioned in the booklet describing the group insurance plan offered to the CSQ members. This booklet contains additionnal information on the provisions applying to the additional plan 1 - Dental care. In this booklet, SSQ designates SSQ, Life Insurance Company Inc. This booklet is provided for information purposes only and in no way alters the stipulations and conditions of the group insurance contract. This booklet is available in French.

4 TABLE OF CONTENTS 1. GENERAL INFORMATION Putting into force of the plan Eligibility for the plan Participation in the plan (including the right to exemption) Effective date of coverage Coverage status available Change in coverage Waiver of premiums in the event of total disability Conversion privilege ELIGIBLE EXPENSES Preventive dental care Basic dental care Major restorative care Deductible common to sections 2.2 and Pre-authorization for treatments Maximum reimbursement Exclusions HOW TO SUBMIT A CLAIM Where to send a claim File and personal information TABLE OF PREMIUMS PER 14-DAY PERIOD

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6 1- GENERAL INFORMATION 1.1 PUTTING INTO FORCE OF THE PLAN For the additional plan 1 - Dental care to come into force in a union, the members must take a vote. When a same union has certifications in more than one employer, separate votes can be taken for each employer Vote in favour of the putting into force of the plan When the vote is in favour of the putting into force of additional plan 1 - Dental care, the plan comes into force on the day that follows the second end of a pay period coinciding with or following the date of the vote, as long as the vote has been taken by June 30 of any year at the latest. If the vote is taken after June 30 of any year, the effective date of the plan is postponed to January 1 of the following year Vote against the putting into force of the plan When members vote against additional plan 1 - Dental care, the plan does not come into force. A new vote cannot be taken within the next 12 months Vote to terminate the plan When the vote is in favour of the termination of additional plan 1 - Dental care, the plan will terminate on the date corresponding to the second end of a pay period coinciding with or following the date of the vote. A new vote cannot be taken within the next12 months. IMPORTANT For termination to be valid, the plan must have been in force for at least 36 months. Page 1

7 1.2 ELIGIBILITY FOR THE PLAN Are eligible for additional plan 1 - Dental care all individuals who are working for a same employer and are members of a same union when the union in question has voted in favour of the putting into force. 1.3 PARTICIPATION IN THE PLAN (INCLUDING THE RIGHT TO EXEMPTION) Compulsory feature Any individual eligible for additional plan 1 - Dental care must participate unless the individual takes advantage of the right to exemption described under the following item Right to exemption a) Beginning of exemption The individual can refuse or cease to participate in additional plan 1 - Dental care as long as there is evidence that the individual is covered by a group insurance plan with a similar coverage. To do so, the individual must complete the Application form or request for change form and provide evidence of the existence of the insurance allowing the exemption. Exemption comes into force on the first day of the pay period following the date SSQ receives the request. b) Termination of exemption The individual exempt from additional plan 1 - Dental care who ceases to be covered by the group plan that allowed exemption can reinstate participation in this plan. To do so, the individual must complete the Application form or request for change form and indicate the reason of termination of the insurance that allowed the exemption. Page 2

8 i) If the employer receives the request for termination of exemption within the 30 days following the termination of the insurance that allowed the exemption The coverage comes into force at the date of termination of the insurance that allowed the exemption. ii) If the employer receives the request for termination of exemption more than 30 days after the termination of the insurance that allowed the exemption The coverage comes into force on the first day of the pay period following the date SSQ receives the request and the applicable premium is payable as of that date. However, no benefits are payable for expenses incurred by new dependent(s) during the threemonth period following the effective date of the coverage. 1.4 EFFECTIVE DATE OF COVERAGE For additional plan 1 - Dental care to come into force at one of the following dates, the employee must be at work or capable of performing the regular duties of the job. Otherwise, the coverage will come into force at the date of the effective return to work. a) If the employer receives the Application form or request for change within 30 days following the date of eligibility* Additional plan 1 - Dental care comes into force at the date of eligibility, according to the coverage status requested (individual, single-parent, family or exemption). Page 3

9 Page 4 b) If the employer receives the Application from or request for change more than 30 days after the date of eligibility Additional plan 1 - Dental care is automatically granted to the employee, with individual coverage, as of the date of eligibility. If the employee requested to be exempt, the exemption is granted as of the first day of the pay period following the date SSQ receives the request. If the employee chose a single-parent or family coverage status, this coverage is granted as of the first day of the pay period following the date SSQ receives the request and the premium is payable as of the same date. However, no benefits are payable for expenses incurred by dependents during the three-month period following the effective date of the coverage requested. *Note: For a newly hired individual signing a contract of employment after the date the individual becomes eligible (contract with retroactive effect), the 30-day period begins on the date the contract of employment is signed. 1.5 COVERAGE STATUS AVAILABLE At the time of application, the individual can choose one of the following coverage status: individual coverage which insures the employee only; single-parent coverage which insures the employee and the dependent children; family coverage which insures the employee, the spouse and the dependent children, if any. IMPORTANT The coverage status held in the health insurance plan does not influence the coverage status selection for additional plan 1 - Dental care. The coverage status held in these two (2) plans can be different and all choices are possible.

10 1.6 CHANGE IN COVERAGE STATUS Increase of coverage status The participant can increase the coverage status in the following ways: change the individual coverage for a single-parent or family coverage; change the single-parent coverage for a family coverage. Increase of the coverage status can only be granted on acknowledgement of new dependents following one of the events listed below: marriage; cohabitation since more than one (1) year (without a minimum period if a child is born of the union or legal procedures of adoption have been undertaken); birth or adoption of a child; termination of the insurance of the spouse or the dependent children. To request an increase, the participant must complete a new Application form or request for change form and return it to the employer. a) If the employer receives the Application form or request for change within the 30 days following the date of acknowledgement of new dependents The new coverage status requested comes into force at the date of the event. b) If the employer receives the Application form or request for change more than 30 days after the date of acknowledgement of new dependents The new coverage status comes into force on the first day of the pay period following the date SSQ receives Page 5

11 the request, and the new premium is payable as of the same date. However, no benefits are payable for expenses incurred by the participant and the dependents, if any, during a three-month period following the effective date of the new coverage status Decrease of coverage status The participant can decrease the coverage status in the following ways: change a family coverage for a single-parent or individual coverage; change a single-parent coverage for an individual coverage. To do so, the participant must complete a new Application form or request for change form and return it to the employer. The new coverage status comes into force on the first day of the pay period following the date the employer receives the request. IMPORTANT Please make sure to inform your employer of any change regarding your dependents so SSQ can be notified. The coverage held in the dental care plan (individual, single-parent or family) must correspond to your current family status to avoid paying unnecessary premiums. 1.7 WAIVER OF PREMIUMS IN THE EVENT OF TOTAL DISABILITY Page 6 When a participant becomes totally disabled before retirement and remains continuously disabled for more than 52 consecutive weeks, the individual remains insured without payment of premiums as of

12 the first working day of the pay period following the 52 th consecutive week of total disability. The waiver of premiums terminates at the first of the following dates: a) the last day of a period of 36 months of waiver for a same period of total disability; b) June 30 coinciding with or following the 65 th birthday. If the participant still receives remuneration from the employer at this date, waiver then terminates at the last day the participant received remuneration from the employer; c) the date at which the period of total disability ends. However, any participant who is totally disabled and who takes a pre-retirement leave with pay cannot benefit from the waiver of premiums during this pre-retirement leave. 1.8 CONVERSION PRIVILEGE There is no conversion privilege for the dental care plan. Page 7

13 2 - ELIGIBLE EXPENSES Eligible expenses are those related to care or treatments administered by a dental surgeon, a specialist or a denturist legally licensed. Eligible expenses are those incurred for the procedures defined hereinafter up to the amounts and procedures provided for in the current edition of the fee guide of the Association des chirurgiens dentistes du Québec (ACDQ) DENTAIDE SYSTEM Electronic transmission of your claims through the Dentaide system is available. Details related to its use are found under chapter PREVENTIVE DENTAL CARE Eligible expenses are reimbursable at 80%, without deductible. The following expenses are eligible for reimbursement: Clinical oral examination X-rays examination not reimbursed by the RAMQ in children less than 10 years old: procedure 01250; recall or periodic examination: procedure 01200; complete examination: procedures 01110, and 01130; emergency examination: procedure 01300; specific oral examination: procedure 01400; complete periodontal examination: procedure Procedures to X-rays (except for the panoramic X-ray, procedure 02600) are included in complete or recall examinations. Page 8

14 2.1.3 Other procedures (laboratory tests and examinations, biopsy and diagnosis casts) Procedures to Preventive care (cleaning, polishing, fluoride treatments, etc.) Scaling Procedures to 13404, and Expenses related to procedures 12400, to and are eligible for reimbursement only for children who are less than 14 years old. Pit and fissure sealants (procedures and 13404) are eligible only on occlusal surfaces of permanent premolars and molars. Procedures to and Control of oral habits and space maintainers Procedures to and to Expenses related to procedures to are eligible for reimbursement only for children who are less than 14 years old General services (anaesthesia) 2.2 BASIC DENTAL CARE Procedures 91110, 91200, 92110, and Eligible expenses are reimbursable at 80% and subject to the common deductible mentioned in section 2.4. The following expenses are eligible for reimbursement: Page 9

15 2.2.1 Minor restoration (amalgam or composite filling) Procedures to (except 21501), and to Note: A same surface or class on the same tooth is eligible for reimbursement once per 12-month period. The equivalent of a bonded amalgam is reimbursed when composite restoration on molars is claimed Endodontics (root canal treatment, root amputation, etc.) Procedures to and to Periodontal treatments (infection treatment, surgery, splinting, etc.) Procedures to 42611, to 43310, to and Procedures and are eligible subject to a maximum of six (6) different sextants per calendar year Oral surgery (removal, alveolectomy, alveoplasty, etc.) Procedures to 72411, and to Procedures 73020, and are eligible subject to a maximum of six (6) different sextants per calendar year. Limitations to sections 2.1 and 2.2 a) Some of the eligible orodental procedures listed under sections 2.1. and 2.2 are subject to a waiting-period before a new request for benefits will be accepted by SSQ. The procedures for which such a minimum waiting-period applies between two (2) dates of Page 10

16 treatment when expenses were eligible and the applicable waitingperiod are indicated in the following schedule: Codes from the ACDQ Number of months 9 months 12 months 24 months 36 months 60 months (2) (1) (6) (4) (3) (1) to (6) (4) (3) (1) (6) (4) (1) (1) (1) (5) to (1) to (1)(3) (5) (1) (1)(3) (1) child less than 14 years old only (2) child less than 10 years old only (3) for a same tooth (4) only one of these codes during the period (5) only one of these codes during the period (6) only one of these codes during the period b) Some of the eligible orodental procedures listed under sections 2.1 and 2.2 are subject to limitations per calendar year or per lifetime of the insured. The orodental procedures and the applicable period are indicated in the following schedule: Once per calendar year 2 times per calendar year 3 times per calendar year Frequency 5 times per calendar year Once per lifetime 5 times per lifetime Codes from the ACDQ (1) (1) (1) (1) child less than 14 years old 2.3 MAJOR RESTORATIVE CARE Eligible expenses are reimbursable at 50% and subject to the common deductible mentioned in section 2.4. Page 11

17 The following expenses are eligible for reimbursement: Removable prosthesis Procedures to 51713, to 57202, and Note: Any fixed bridge will be covered up to the cost and limitations of an equivalent removable denture. Limitations to section 2.3 When a benefit claim has been made for a removable prosthesis and that eligible expenses were acknowledged, a replacement prosthesis will not be eligible for reimbursement if it is installed within the 60 months following the installation of the previous one. However, a permanent removable prosthesis, partial or full, is eligible for reimbursement if it replaces a transitional removable prosthesis (partial or full) and is installed within six (6) months of the installation date of the transitional prosthesis. 2.4 DEDUCTIBLE COMMON TO SECTIONS 2.2. AND 2.3 Basic dental care and major restorative care are subject to a common deductible of $50 per calendar year. This is a single deductible applying to expenses incurred by both the participant and the dependents (deductible per certificate). 2.5 PRE-AUTHORIZATION FOR TREATMENTS When the total cost of the treatment is expected to exceed $800 or the scheduled services are major restorative care, SSQ must be provided with a treatment plan including an X-ray before the beginning of the treatment to determine the amount of expenses that will be covered. Furthermore, preoperative X-rays, periodontal scales, photographs, study casts or other supporting evidence can be required for the analysis and the authorization of some care (even if the care has already been received). Page 12

18 2.6 MAXIMUM REIMBURSEMENT All the care listed under sections 2.1, 2.2 and 2.3 are subject to a maximum reimbursement per insured, per calendar year, as indicated in the following table. The first calendar year corresponds to the year during which the additional plan 1 - Dental care becomes effective. Calendar year Maximum reimbursement per insured First $600 * Second $800 Third and following years $1,000 * The maximum reimbursement of $600 provided for the first calendar year applies regardless of the effective date of the plan (no prorata). 2.7 EXCLUSIONS No benefits are payable for expenses incurred: a) as a result of a war, insurrection or riot; b) as a result of participation in a criminal act; c) while the insured is an active member of the armed forces; d) for services the insured is not required to pay; e) for esthetic purposes, except if otherwise specified; f) that are reimbursed or payable by a government plan or organization; g) for medical examinations for work, insurance, control or verification purposes; h) that are reimbursed or payable by any other private, individual or group plan; i) for services or supplies, examinations, care, expenses, or their surplus, that are not in compliance with the reasonable standards of the common practice of the health professionals involved; j) for products, devices or services used or offered for experimental purposes or in the medical research stage, or whose use does not comply with the indications approved by the proper authorities or, failing such authorities, with the indications given by the manufacturer. Page 13

19 Furthermore, any act, treatment, prosthesis, of any nature, related to a dental implant is not eligible. NOTE All the orodental procedures previously listed are taken from the 2002 edition of the fee guide of the Association des chirurgiens dentistes du Québec (ACDQ). Page 14

20 3 - HOW TO SUBMIT A CLAIM To have your claim electronically transmitted to SSQ, please present your Dentaide card to the participating dentist. You will only have to pay the portion of eligible expenses that is not reimbursable by SSQ. If the dentist is not a member of Dentaide, you must ask the dentist to complete the Benefit claim for dental care form and you must sign and return this form to SSQ. The form can be obtained from the employer. We recommend that you send in the original of your paid invoices every three (3) months. Please keep a copy of these invoices since they are not returned to you. Any invoices submitted more than 12 months after the date expenses were incurred are not eligible for reimbursement. 3.1 WHERE TO SEND CLAIMS Please indicate your contract number on any claims or other correspondence sent to SSQ, at the following address: SSQ, Life Insurance Company Inc. P.O. Box 10500, Sainte-Foy Station Sainte-Foy, Quebec G1V 4H6 3.2 FILE AND PERSONAL INFORMATION To insure the confidentiality of personal information that concerns you, SSQ opens an insurance file containing information on your insurance application as well as information relative to any claims for insurance benefits. Files are kept at the head office of SSQ in Sainte-Foy. Only employees or authorized agents in charge of underwriting services, investigations and claims, as well as the persons you have authorized, have access to your file. Page 15

21 Page 16 You are entitled to consult the personal information held in this file and have it corrected, if need be, by sending a written request to the attention of the person responsible for access to information at the address indicated in the previous section.

22 4 - TABLE OF PREMIUMS PER 14-DAY PERIOD Coverage status Premium per 14-day period* Individual $7.47 $7.99 Single-parent $11.35 $12.14 Family $18.81 $20.13 * The 9% sales tax must be added. Page 17

23 Page 18 NOTES