UNIVERSITY OF NEW BRUNSWICK GROUP SUPPLEMENTARY HEALTH PLAN

Transcription

1 The UNB Group Supplementary Health Plan is designed to provide medical coverage in addition to the basic medical coverage provided through Medicare New Brunswick. ELIGIBILITY FOR COVERAGE Coverage is compulsory for the following types of employment contracts: Continuing Full-Time An employee who works 29 or more hours each week and whose appointment is expected to last at least 12 months. Continuing Part-Time An employee who works 13 or more hours each week and whose appointment is expected to last at least 12 months. Continuing Term Appointment A full-time employee with a term appointment of eight months or more. The date of eligibility to become a Plan member is normally specified in the employee's employment contract letter. If an employee has comparable health coverage provided under a spousal plan, the employee will be permitted to opt out of the UNB Group Supplementary Health Plan. However, if this comparable coverage ceases, the employee must apply for coverage under the UNB Group Supplementary Health Plan within 31 days. COVERAGE FOR SPOUSE AND DEPENDENTS Coverage is provided for the employee and the employee's eligible dependents which may include their spouse or partner and/or dependent children. Spouse - is defined as the employee's legally married spouse or the partner who has been living with the employee in a spousal relationship for at least 12 consecutive months. Child - is defined as: a) an employee's or spouse's natural or legally adopted child, step child or legal ward under the age of 19, who is unmarried and dependent on the employee for support, or under the age of 24 and attending an accredited school, college or university on a full-time basis. b) an unmarried child over the age of 19 who is dependent on the employee for support because of a mental or physical handicap. CHANGE OF DEPENDENT STATUS Changes in marital and family status have a direct impact on benefits, therefore it is important that the employee notify Human Resources within 31 days of the change. CONTINUATION OF COVERAGE Health Insurance coverage may be continued for the following circumstances provided arrangements are made with UNB Human Resources to pay the required premium. During A Period Of Disability Coverage may continue during the period in which an employee receives a benefit from the University's Long Term Disability Plan. During A Leave Of Absence Coverage may continue for the duration of an employee's approved leave of absence. Upon Retirement Coverage may continue beyond retirement for an employee and their eligible dependents under the Group Supplementary Health Plan for Retired Employees. Continuation Of Dependent Coverage Upon the Death of an Employee If a covered employee dies, the employee's spouse and dependent children will be eligible to continue their insurance coverage under the Group Supplementary Health Plan for Retired Employees. TERMINATION OF COVERAGE Coverage for an employee terminates: 1. On termination of employment. 2. On retirement or June 30th following the employee's 65th birthday. 3. On termination of the policy. Page 1 of 6

2 Coverage for a dependent terminates: 1. On the date the employee's coverage terminates. 2. On the date the employee's classification does not include dependent coverage. 3. On the date they cease to meet the definition of an eligible dependent under the Plan. 4. On termination of the policy. REINSTATEMENT An employee, whose insurance has been terminated due to a leave of absence without pay, will have their insurance reinstated on the first day that they are actively at work. REASONABLE AND CUSTOMARY CHARGES Payment of claims is based on "reasonable and customary charges" which exclude amounts in excess of the fees usually charged for service, treatment, or supplies in the absence of insurance or amounts which are in excess of the general level of fees charged in the area. SUBMISSION OF CLAIMS It is essential that receipts for all eligible expenses: 1. state the name of the person for whom the expense was incurred and other personal information as may be required; 2. state all necessary information about the expense; 3. state the date that the expense was incurred; and 4. be submitted for payment within 18 months from the date the expense was incurred. Expenses Incurred Within New Brunswick Receipts for reimbursement of expenses which have been incurred within New Brunswick may be submitted to the local Blue Cross office for payment. BENEFITS PROVIDED 1. VISION CARE Vision Benefits every 24 consecutive months and every 12 months for dependent children under 19 years of age (eye exams / lenses / contact lenses / frames), to a maximum eligible expense of $ EXTENDED HEALTH CARE COVERAGE While Medicare provides for basic health benefits, it does not pay for all health care costs. The Extended Health Care benefit is designed to help pay the cost of various types of medical charges resulting from illness or injury. The amount of benefit payable will depend upon the charges incurred but this Plan does not duplicate any government hospital or medical insurance benefit. The Plan provides up to 100% reimbursement of the following items when they are medically required. Some items must be prescribed or approved in writing by the attending physician. < AMBULANCE - emergency ambulance service to the nearest hospital equipped to provide required treatment, when the physical condition of the patient precludes any other means of transportation. < Purchase of ARTIFICIAL LIMBS or OTHER PROSTHETIC APPLIANCES. < DIABETIC SUPPLIES including lancets, needles, syringes and chemical diagnostic aids. < Purchase of a HEARING AID (after one year of plan membership) to a maximum of $750 in any 60 consecutive months (doctor's prescription and audiologist report required). < HEARING AID REPAIRS (not including batteries). Expenses Incurred Outside of New Brunswick Assistance on reimbursement of expenses which have been incurred outside of New Brunswick, may be obtained by contacting UNB Human Resources. Page 2 of 6

3 < MEDICAL APPLIANCES: a) such as casts, slings, and splints; b) rental or purchase (upon insurance provider's approval) of a hospital bed and other similar durable medical equipment designed primarily for therapeutic purposes; c) crutches, canes and walker; d) wheelchair rental (or purchase upon insurance provider s approval), including replacement (up to once every five years) and repairs. < ORTHOPAEDIC SHOES: a) charges for custom moulded arch supports to accommodate, relieve, or remedy some mechanical foot defect or abnormality as prescribed by an orthopaedic surgeon, physiatrist, rheumatologist or the attending Physician to a maximum of $200 for each member in a calendar year. b) charges for orthopaedic shoe(s) when the shoe(s) is (are) customized with special features to accommodate, relieve, or remedy some mechanical foot defect or abnormality as prescribed by an orthopaedic surgeon, physiatrist, rheumatologist or the attending Physician. Also, charges for shoe modification and adjustment supplies when prescribed by one of the Health Care Professionals noted above to accommodate, relieve, or remedy some mechanical foot defect or abnormality. The maximum eligible expense for orthopaedic shoe(s) and adjustment supplies is $250 for each member in a calendar year. Documents required for claim purposes are: a) a prescription from a medical doctor, podiatrist or chiropodist, b) a paid-in-full receipt, c) a copy of the analysis or written confirmation from the provider of the biomechanical evaluation/gait assessment. < PARAMEDICAL SERVICES: Services of the following practitioners, will be limited to a maximum of $650 per practitioner and overall maximum for all practitioners of 50 treatments per insured individual per calendar year, including: Chiropractor (including x-rays); Naturopath to a maximum initial visit charge of $80 and subsequent per visit charge of $50; Osteopath; Podiatrist/Chiropodist; Physiotherapist (physician s prescription required); Massage Therapist to a maximum per visit charge of $60 (physician s prescription required). The following providers will not be included in the above noted practitioner category and will be covered as follows: < Psychologist (to a maximum of $75 per visit, eligible after one year of plan membership, (physician s prescription required); < Speech therapist (physician s prescription required). No maximum. < REGISTERED NURSING SERVICES: Charges for nursing care performed at the member s residence (other than a convalescent or nursing home) on the written authorization of the attending Physician. The nurse must be a Registered Nurse or Licensed Practical Nurse and must be currently registered with the appropriate nurses association and must not be a resident at the member s home or related to a member s family by blood or marriage. The maximum eligible expense for each insured member will be limited to $10,000 in a calendar year. < SEMI-PRIVATE hospital accommodation. < X-RAY examinations and diagnostic laboratory services. < OXYGEN, PLASMA and BLOOD TRANSFUSIONS. Page 3 of 6

4 4. MAJOR MEDICAL DENTAL Services of a dentist for procedures listed in the Major Medical Dental Schedule including the treatment of a fractured jaw or injuries to natural teeth provided expenses are incurred with six months of the injury. 100% reimbursement for eligible expenses as stated in the New Brunswick Dental Society Fee Guide that is in current use as the basis of adjudication under the group dental policy. MAJOR MEDICAL DENTAL SCHEDULE Incision and drainage of abscess Code Surgical removal, impaction Code Removal, residual roots Code Alveoloplasty (not in conjunction with extractions) Code Gingival curettage Code Gingivectomy Code Gingivoplasty and/or stomatoplasty, independent procedure Code Surgical Removal Biopsy Code PRESCRIPTION DRUG COVERAGE < Prescription Drugs (including serum, vaccines and injectables) which by law require a Physician s or Dentist s prescription except those over-the-counter medications included on Benefit List C of Medavie Blue Cross, on the date the medication is dispensed; < Needles, syringes and chemical diagnostic aids for the treatment of diabetes; < intra-uterine devices and diaphragms; < Supplies of a non-prescription nature required as a result of a colostomy and/or an ileostomy; < Smoking cessation aids limited to one attempt to quit smoking per person per lifetime to a maximum amount of $500; REIMBURSEMENT A) REPAYMENT RATE Prescription Drugs: The Plan pays 100% of the least costly generic substitute unless the prescribing physician requests no substitute. This is subject to a maximum amount of $5.00 on the pharmacist's dispensing fee per prescription and a maximum of 9.5% on the ingredient cost mark-up. Cysts/Granulomas Code Benign Tumours Code Antral surgery Code Treatment of Fractures Code If two or more surgical procedures are performed during one appointment, repayment is made according to the scheduled amount for the first procedure and at 50% of the scheduled amount for other procedures. Page 4 of 6

5 B) BLUE CROSS MEMBER IDENTIFICATION CARD The Blue Cross member identification card may be presented to the pharmacy for drug prescriptions filled in New Brunswick: 1) If the pharmacy is participating in UNB's reimbursement schedule, there will be no further charge. 2) If the prescription is filled at a pharmacy that is not participating in UNB's reimbursement schedule, the employee is responsible for paying any difference in fees. 3) If the pharmacy cannot accept the Blue Cross member identification card for payment of an eligible drug expense as defined under Covered Expenses, item (a), a paid-in-full receipt can be presented for reimbursement to the nearest Blue Cross customer service centre. In this situation, you should ask for a breakdown of the dispensing fee and the ingredient cost mark-up as Blue Cross needs this information to adjudicate the reimbursement. Attached to this brochure is a list of pharmacies that have indicated that they will meet the maximum reimbursement limit. Page 5 of 6

6 PARTICIPATING PHARMACIES FREDERICTON AREA 471 Smythe St. Phone: (506) Northside Pharmasave 231 Canada St. Phone: (506) Southside Pharmasave 640 Prospect St. West Phone: (506) Ross Drug 402 Queen St. Phone: (506) Ross Drug 206 Rookwood Ave. Phone: (506) Ross Drug 1128 Smythe St. Phone: (506) Regent Mall, 1399 Regent St. Phone: (506) New Maryland Pharmacy New Maryland Hwy. 101 New Maryland, NB Phone: (506) Oromocto PharmaChoice 66 Broad Road, Oromocto, NB Phone: (506) Medicine Shoppe Fredericton Direct Charge Co-op 170 Doak Road (506) SAINT JOHN AREA 168 Rothesay Ave. Phone: (506) Millidgeville Market 650 Somerset Street Phone: (506) Supervalue Pharmacy Lancaster Mall 621 Fairville Blvd Phone: (506) Westmorland Road Phone: (506) MONCTON AREA 175 Trinity Drive Moncton, NB Phone: (506) Champlain Place 477 Paul St. Moncton, NB Phone: (506) BATHURST AREA 700 St. Peter s Ave. Bathurst, NB Phone: (506) Chaleur Centre 400 Route 430 Unit 14 Big River, NB Phone: (506) Page 6 of 6