2012 2013
Extended Health Care Insurance This brochure will provide you with information about the Ontario Dental Association s (ODA) Extended Healthcare (EHC) Insurance Plan. Eligibility The plan is available to ODA members and their dependents (families) as well as staff of ODA members and their dependents (families). It is a comprehensive, competitively priced healthcare plan developed by Dentists for Dentists and one that the ODA is proud to offer to its members and their staff. Coverage is provided through Great West Life Assurance Company of Canada and has insured the ODA EHC plan since 1983. If you have any questions about the plan or completion of the enclosed application forms please contact us at 416-922-4162 Ext. 3368, or at 1-866-739-8099 Ext. 3368 or by email at ehc@oda.ca When you apply, regular underwriting procedures will be followed by Great West Life, and reported to the Medical Information Bureau. Should further information be required in order to assess your insurability, you or your physician will be contacted in writing by the underwriter at Great West Life. Upon approval by Great West Life, coverage would be effective on the 1st day of the month 90 days from the date the application is received. what s inside Eligibility...3 Plan Coverage...4 Plan Coverage GOLD...5 DEPENDENTS are defined as spouses and unmarried children of the plan participant. Children remain eligible as dependents under the following conditions: Until their 21st birthday, or; If in full time attendance at a University or similar learning institution within Ontario, Canada or outside of Ontario, Canada, until graduation, or; 21 years of age and older who are incapable of supporting themselves because of mental or physical handicap and who were insured under the plan on the day before their 21st birthday. Plan Coverage SILVER...6 Plan Coverage BRONZE...7 Monthly Premiums...8 Points to Note...9 Out of Country Coverage...10 Limitations...11 2 DENTAL OFFICE STAFF must be working for an ODA member as regular staff working a minimum of 20 hours per week. Temporary, part-time and seasonal employees are not eligible. NOTE: THE PLAN DOES NOT COVER: Children who are working more than 30 hours per week unless they are full time students, or spouses or children who are not residing in Canada or the United States. 3
Plan Coverage There are three levels of coverage: Following are examples of some of the services and supplies covered under the plan dollar limits are per insured person: GOLD GOLD covers 90% of eligible expenses SILVER covers 80% of eligible expenses Special Notice BRONZE covers 70% of eligible expenses If you currently have medical coverage and will be losing your coverage, contact us within 31 days of losing your coverage and it is not necessary to complete the Evidence of Insurability/Coverage Detail Form or the Medical Questionnaire. We will automatically enroll you in our plan with coverage beginning the day after your current coverage ends. Complete only the Application Form and send it to the ODA in the envelope provided, completing the information required on the reverse of the form. Prescription drugs to the cost of a brand name when prescribed by a doctor and dispensed by a pharmacist (deferred drug card) Injectable drugs when administered by a doctor other than vaccines Treatment by a licensed physiotherapist when prescribed by a physician - $1,500.00 per person per benefit year Treatment by a licensed psychologist or social worker - $1,050.00 per person per benefit year Treatment by a registered chiropractor, massage therapist, speech therapist, chiropodist, osteopath, podiatrist, naturopath or acupuncturist - $500.00 per practitioner, per person, per benefit year Private hospital room coverage Eye examinations once every 24 months ages 20 to 64 Visioncare $250.00 per person every 24 months Orthotics one pair of custom made shoes or inserts per benefit year up to a maximum of $450.00 per person Diabetic supplies CPAP machines rental or purchase up to $1,500.00 Various assistive devices such as wheelchairs, walkers, canes, rental or purchase of a hospital bed, etc Out of Country emergency medical coverage (180 day duration) There is no deductible with the GOLD level of coverage. All eligible expenses are reimbursed at *90% of claims submitted. Out of country expenses are reimbursed at 100% and are not subject to a deductible. (*90% coverage on the first $10,000.00 covered benefit year expenses per family and 100% thereafter.) 4 5
SILVER Prescription drugs to the cost of a generic when prescribed by a doctor and dispensed by a pharmacist (no drug card) Injectable drugs when administered by a doctor other than vaccines Treatment by a licensed physiotherapist when prescribed by a physician $1,000.00 per person per benefit year Treatment by a licensed psychologist or social worker $1,050.00 per person per benefit year Treatment by a registered chiropractor, massage therapist, speech therapist, chiropodist, osteopath, podiatrist, naturopath or acupuncturist - $400.00 per practitioner, per person per benefit year Semi-private hospital room coverage Eye examinations once every 24 months ages 20 to 64 Visioncare $150.00 per person every 24 months Orthotics one pair of custom made shoes or inserts per benefit year up to a maximum of $450.00 per person Diabetic supplies CPAP machines rental or purchase up to $1,500.00 Various assistive devices such as wheelchairs, walkers, canes, rental or purchase of a hospital bed etc Out of Country emergency medical coverage (180 day duration) All expenses within Canada are subject to the following deductible: Benefit year deductible for Single coverage - $200.00 Benefit year deductible for Couple coverage - $400.00 Benefit year deductible for Family coverage - $400.00 All eligible expenses are covered at *80% of claims submitted Out of Country expenses are covered at 100% of claims submitted (subject to the plan deductible) (*80% coverage on the first $10,000.00 covered benefit year expenses per person and 100% thereafter.) BRONZE Prescription drugs to the cost of a generic when prescribed by a doctor and dispensed by a pharmacist (no drug card) Injectable drugs when administered by a doctor other than vaccines Treatment by a licensed physiotherapist when prescribed by a physician $500.00 per person per benefit year Treatment by a licensed psychologist or social worker $1,050.00 per person per benefit year Treatment by a registered chiropractor, massage therapist, speech therapist, chiropodist, osteopath, podiatrist, naturopath or acupuncturist - $300.00 total all practitioners per person per benefit year Semi-private hospital room coverage Eye examinations once every 24 months ages 20 to 64 Orthotics one pair of custom made shoes or inserts per benefit year up to a maximum of $450.00 per person Diabetic supplies CPAP machines rental or purchase up to $1,500.00 Various assistive devices such as wheelchairs, walkers, canes, rental or purchase of a hospital bed etc Out of country emergency medical coverage (90 day duration) All expenses within Canada are subject to the following deductible: Benefit year deductible for Single coverage - $250.00 Benefit year deductible for Couple coverage - $500.00 Benefit year deductible for Family coverage - $500.00 All eligible expenses are covered at *70% of claims submitted Out of Country expenses are covered at 100% of claims submitted (subject to the plan deductible) (*70% coverage on the first $10,000.00 covered benefit year expenses per person and 100% thereafter.) 6 7
Monthly Premiums The following rates are in effect from July 1st, 2012 to June 30th, 2013 COVERAGE DIV. 1 DIV. 2 DIV. 3 BRONZE SINGLE $48.12 $79.32 $96.25 COUPLE $91.99 $154.39 $179.44 FAMILY $135.87 $199.43 $221.05 SILVER SINGLE $72.60 $120.21 $145.55 COUPLE $139.56 $234.79 $272.53 FAMILY $206.52 $303.53 $336.02 GOLD SINGLE $137.95 $224.43 $271.58 COUPLE $266.77 $439.71 $510.19 FAMILY $395.60 $568.89 $629.50 The rates above may be paid on a Quarterly, Semi-annual or Annual basis (monthly payments are not available). Premiums may be paid by cheque, VISA, or Mastercard. Rates are effective for a one year period, and are effective from July 1st to June 30th of the following year. The Benefit Year for the Extended Health Care Plan runs from July 1st to June 30th of the next year. Expenses and deductibles are calculated using these dates. Any premium increases are based upon plan experience for the group, and not on an individual basis. Points to Note Upon coverage approval by Great West Life, we will notify you by letter providing you with your personal ID#, a booklet (Gold, Silver or Bronze) describing plan benefits and other valuable information about your coverage. Dependent children who are unable to care for themselves due to mental or physical handicap are covered for the life of your coverage, providing they were insured as a dependent prior to their 21st birthday. Also, dependent children who are full time students are covered until graduation regardless of their age. Dental office staff must be employed by a member of the ODA in order to be eligible for coverage. Therefore, if a non-dentist insured changes employers, the new employer must be an ODA member in order for the coverage to continue. Dentists may continue coverage on the plan after retirement as long as they remain a member of the ODA in any category. There is no age limit for our plan. Non-dentists who retire may stay on the plan as long as they were on the plan and employed by a member dentist for a minimum of 5 years. 8 9
Out of Country Coverage Your Great West Life Group Policy protects you and your eligible dependents against unforeseen medical emergencies which may arise while you are temporarily traveling outside of Canada. The coverage is for emergency medical situations only. Coverage under your Great West Life plan is only available if your claim is eligible for payment by your provincial health plan. It is recommended that you contact your provincial health plan prior to leaving the country to determine the extent of your coverage. Benefits under your Great West Life plan are also subject to coordination with other insurance carriers. If you have purchased additional travel insurance, Great West Life will coordinate the payment of benefits directly with your other carrier. ELIGIBILITY In order for a claim to be eligible, you or your dependents must: meet eligibility requirements be eligible for coverage under your provincial health plan be traveling for business, vacation or educational reasons IN ADDITION your Provincial health plan must pay a portion of the charge treatment must be required for an emergency or unexpected illness only COVERAGE Your plan covers 100% of the following expenses relating to the initial emergency treatment, subject to the plan deductible (for Silver and Bronze levels of coverage only): treatment by a licensed physician, including diagnostic x-ray and laboratory services in-patient hospital accommodations in a standard or semi-private ward or intensive care unit medical supplies provided during a covered hospital confinement paramedical services provided during a covered hospital confinement hospital out-patient services and supplies ambulance transportation LIMITATIONS There is no coverage for the following types of expenses ongoing or follow up care or rehabilitation after treatment of the initial emergency ongoing investigations or diagnostic procedures after treatment of the initial emergency non emergency or routine management of a pre-diagnosed medical condition or following an emergency if you or a dependent experience a medical emergency outside of Canada, and there is no suitable medical facility available to treat the emergency, Great West Life and Medex will arrange to have you evacuated to the nearest suitable medical facility. Your Global Medical Assistance coverage provides for unexpected travel expenses associated with a medical emergency. Some examples are identified below: Hotel Accommodations if the return trip is delayed due to hospitalization, up to $1,500.00 Airfair if a prepaid prearranged flight is missed due to hospitalization Vehicle Return if you are medically precluded from driving back to Canada, up to $1,000.00 Transportation of mortal remains back to Canada in the event of a death. Through the Medex Communications Network, you have direct access 24 hours a day for worldwide assistance in emergency medical situations. Medex can assist you both in locating qualified care, and guaranteeing payment on Great West Life s behalf. As well, Medex can assist you in your travel arrangements, and provide verification of Great West Life coverage as arrangements are made. 10 11
4 New Street, Toronto, ON M5R 1P6 Tel 416-922-3900 Fax 416-922-9005 www.oda.ca 05/2012 2012