Health Benefits Trust Fund Benefits Guide

Health Benefits Trust Fund Benefits Guide 2015

Contents Welcome... 2 Benefits Eligibility... 3 Physicians... 3 Medical Office Staff... 3 Definition of Dependents... 4 Participation Requirements... 5 Rates... 6 Enrollment... 7 Benefit Summary... 8 Life Insurance for Medical Office Staff... 8 Accidental Death & Dismemberment for Medical Office Staff... 8 Long Term Disability for Medical Office Staff... 8 Extended Health Care... 9 Dental Care... 12 How to Submit a Claim... 14 Optional Cost-Plus Benefit... 16 Cost Plus Claims Process... 18 Coordination of Benefits... 20 1

Welcome Welcome to the Health Benefits Trust Fund (HBTF) benefits program. The HBTF plan is a comprehensive health and dental benefit plan for physicians and their office staff. It includes an employee benefit package of Life, Accident & Disability insurance coverage specifically for medical office staff. This Benefits Guide highlights the key features of the HBTF benefits plan. It provides details about health and dental care coverage and other benefits available to medical office staff, and it walks you through the enrollment process step by step. This Benefits Guide is intended to provide you with easy-to-understand explanations of certain key features of the HBTF benefits. It does not include the complete details of the benefits plan. These are contained in the plan booklets. Every effort has been made to ensure the accuracy of the information contained in this guide. However, if there is ever a conflict or difference between what is written here and the plan documents, the plan documents will take precedent. The personal data we receive when enrolling you in the HBTF plan is protected by our privacy code. Your personal information is managed in accordance with the provisions of the Personal Information Protection Act. For questions or additional assistance contact an Insurance Administrator: Doctors of BC (British Columbia Medical Association) 115 1665 West Broadway Vancouver BC V6J 5A4 Direct Line: (604) 638-2818 or 638-7856 Toll Free: 1-800-665-2262 (local 2818 or 7856) Fax: (604) 638-2909 2

Benefits Eligibility Physicians Physician members are eligible to participate in the HBTF plan if you are a resident of Canada, are entitled to benefits under a provincial or territorial medicare plan or federal government plan that provides similar benefits and meet the following conditions: You are an active member of Doctors of BC or the Yukon Medical Association. You are under age 65 at the time of enrollment, or you are transferring from the Core Plus plan at age 55 or older and you are no longer working 20 hours per week and no longer qualify for that plan. Proof of good health will be required unless you apply for the coverage within 90 days of becoming a Doctors of BC member for the first time or within 90 days of completing residency. If you apply for coverage within these time limits, no waiting period will apply to your coverage. If you apply for coverage outside of these timelines proof of good health will be required and the effective date of coverage will be set by Sun Life upon approval. Medical Office Staff Medical Office Staff are eligible to participate in the HBTF plan and must enroll if you are a resident of Canada, are entitled to benefits under a provincial or territorial medicare plan or federal government plan that provides similar benefits and meet the following conditions: You are an employee of a plan participant who is a member Doctors of BC or the Yukon Medical Association. You are under age 65 at the time of enrollment. You are actively working at least 20 hours per week in a Medical Practice in the province of BC or the Yukon Territory. You have completed the waiting period. Proof of good health will be required unless you apply for the coverage within 90 days of becoming eligible for coverage. Proof of good health is required for all amounts of Long Term Disability coverage over $1,000. There is a 3 month waiting period before new Medical Office Staff are eligible to participate in the plan. This means once enrolled coverage becomes effective on the first of the month following completion of 3 months of employment. Your dependents become eligible for coverage on the date you become eligible or the date they first become your dependent, whichever is later. You must apply for coverage for yourself in order for your dependents to be eligible. 3

Definition of Dependents Your dependent must be your spouse and/or your child and a resident of Canada or the United States. Your spouse by marriage or under any other formal union recognized by law, or your partner of the opposite sex or of the same sex who has been publicly represented as your spouse for 12 months, is an eligible dependent. At 12 months of cohabitation, your partner is eligible to be enrolled in the plan. You can only cover one spouse at a time. Your children and your spouse's children (other than foster children) are eligible dependents until the last day of the month during which the children reach age 22, as long as they are not married or in any other formal union recognized by law. A child who is a full-time student is attending an educational institution recognized under the Income Tax Act (Canada) is also considered an eligible dependent until the last day of the month during which the child reaches age 25, as long as the child is entirely dependent on you for financial support. If a child becomes handicapped before the limiting age, coverage under the plan will continue as long as: the child is incapable of financial self-support because of a physical or mental disability, and the child depends on you for financial support, and is not married nor in any other formal union recognized by law. 4

Participation Requirements The participation requirements outline the number of physicians and their employees who must agree to join the plan in order for benefits to be offered to the office. The requirements are as follows: Number of Eligible Applicants in Office Minimum Participation 5 or fewer 100% 6 5 out of 6 7 6 out of 7 8 7 out of 8 9 8 out of 9 10 or more 75% (rounded up) Doctors are not eligible to participate in the HBTF Life, AD&D and Long Term Disability plans. All new applicants in a participating office must enroll in the plan. Eligible applicants who already have health and dental coverage under another group plan may waive their participation in those benefits. Medical Office Staff must enroll for Life, AD&D and Long Term Disability even if they waive health and dental coverage. 5

Rates Benefit $/month $/month $/month $/month 1 st Year Medical Physicians Office Staff Post 1 st year Physicians Under Age 70 Life Insurance (Employees Only) $20,000 $2.72 $50,000 new option $6.80 Accident Insurance (Employees Only) $20,000 $0.58 $50,000 new option $1.45 Long Term Disability (Employees Only) $500 (closed to new entrants) $12.63 $600 (closed to new entrants) $15.15 $700 (closed to new entrants) $17.68 $800 (closed to new entrants) $20.20 $900 (closed to new entrants) $22.73 $1,000 $25.25 $1,100 (closed to new entrants) $27.78 $1,200 $30.30 $1,500 $37.88 $2,000 $50.50 $2,500 new option $63.13 Physicians Over Age 70 Extended Health & Dental single member $54.34 $108.67 $108.67 $117.31 member with 1 dependent $99.62 $199.23 $199.23 $215.08 member with 2 or more dependents $148.09 $296.18 $296.18 $319.73 Cost Plus Administration Fee An administration fee is applied to the processing of Health and/or Dental claims under the Cost Plus portion of the Plan, and is intended to cover Doctors of BC s cost of administering and assessing these claims. The administration fee is 7% of the eligible claim amount with a minimum charge of $25 and a maximum charge of $250 per claim. For efficiency in costs and administration, there is a minimum claim submission amount of $100. (The minimum claim submission amount is $100 or the amount of outstanding expenses to be claimed at December 31 of a benefit year, if less than $100). 6

Enrollment To apply for coverage the member physician must first complete the Employer Agreement with the Trustees. This is a contract between the physician/professional corporation and the Health Benefits Trust Fund. The agreement specifies who is to be covered by the HBTF plan. Once this agreement has been completed then each physician and any eligible medical office staff must complete and sign a HBTF Plan Enrollment Form. Completed HBTF Plan Enrollment Forms should be submitted to Doctors of BC Insurance Administrators as soon as the applicant is eligible. If necessary, the Insurance Administrator will send a confidential Health Questionnaire directly to the Applicant. Please see Benefits Eligibility section for information on when proof of good health will be required. 7

Benefit Summary Life Insurance for Medical Office Staff Amount: Choice of $20,000 or $50,000 Waiver of Premium: Premiums waived if you become totally disabled before retirement or age 65, whichever is earlier. Termination: Coverage will end when you retire or reach age 65, whichever is earlier. However, coverage can be continued until age 70, provided that you continue to be actively working for your employer at least 20 hours a week and you continue to meet all of the eligibility requirements. Accidental Death & Dismemberment for Medical Office Staff Amount: Choice of $20,000 or $50,000 if death is result of an accident Benefits for the loss of or loss of use of, a portion of the body which occur within one year after the date of the accident are in relation to the severity of the injury received. Waiver of Premium: Premiums waived if you become totally disabled before retirement or age 65, whichever is earlier. Termination: Coverage will end when you retire or reach age 65, whichever is earlier. However, coverage can be continued until age 70, provided that you continue to be actively working for your employer at least 20 hours a week and you continue to meet all of the eligibility requirements. Other Benefits: Continuation of Coverage Conversion Option Critical Disease Benefit Day Care Benefit Education Benefit Family Transportation Benefit Funeral Expense Benefit Home Alteration & Vehicle Modification Rehabilitation Benefit Repatriation Benefit Seat Belt Benefit Spousal Retraining Benefit Long Term Disability for Medical Office Staff The Long Term Disability Benefit provides a monthly benefit to staff members if they are totally disabled and unable to work. Amount: Choice of $1,000, $1,200, $1,500, $2,000 or $2,500 per month. The amount elected should not exceed 85% of the employee s monthly gross income. 8

Elimination Period: Benefits are payable after 17 weeks of continuous disability. Maximum Benefit Period: If you become disabled prior to age 64, benefit payments end the earlier of the date you are no longer disabled or the last day of the month in which you reach age 65. If you become after age 64, benefits are payable for a maximum of 12 months, but in no event will they continue beyond age 70. Taxability: Definition of Total Disability: The monthly benefits payable by the insurance company to the office staff while disabled will be taxable. Employee is considered totally disabled if, as the result of injury or illness he/she is unable to perform the essential duties of his/her regular occupation in the first 24 months of disability. After 24 months, total disability means the inability to earn more than 75% of indexed pre-disability earnings from the employee s own or any other occupation for which he/she is or may become reasonably suited by education, training or experience. Termination: Coverage will end when you retire or the day you reach age 65 less the elimination period of 119 days, whichever is earlier. Extended Health Care Physicians 9 Medical Office Staff Annual Deductible $50/Single & $100/Family $50/Single & $100/Family Drug Dispensing Fee $8 per script $8 per script Prescription Drugs Reimbursed at 80% The maximum for members over age 70 and their dependents is $3,000 per benefit year per person. The maximum for members 80% (and their dependents) who transferred from the Core Plus Plan after January 1, 2014 due to reduced work hours at age 55 or older is $3,000 per benefit year per person. Infertility Drugs 80% to a lifetime maximum of 80% to a lifetime maximum of

$2,400 per person $2,400 per person Licensed Ambulance 80% 80% Osteopath, chiropractor, podiatrist, chiropodist, physiotherapist, naturopath, massage therapist 80% to a maximum of $500 per person per specialty per benefit year to a combined overall maximum of $1,000 80% to a maximum of $500 per person per specialty per benefit year to a combined overall maximum of $1,000 Psychologist or Social Worker 80% to a maximum of $1,000 80% to a maximum of $1,000 per person per benefit year Speech Therapist 80% to a maximum of $1,000 per person per benefit year Private Duty Nursing Reimbursed at 80% The maximum for members under age 70 and their dependents is $10,000 per benefit year per person. per person per benefit year 80% to a maximum of $1,000 per person per benefit year The maximum for members over age 70 and their dependents is $25,000 lifetime per person. 80% up to a maximum of $10,000 per person per year The maximum for members (and their dependents) who transferred from the Core Plus Plan after January 1, 2014 due to reduced work hours at age 55 or older is $25,000 per lifetime per person. Hospital 100% Private Room 100% Private Room Convalescent Hospital 100% up to $20 per day to a 100% up to $20 per day to a maximum of 180 days maximum of 180 days Medical Services & Equipment Dental Accident (repair) for services received within 12 months of the accident Wigs to a lifetime maximum of $500 per person Breast Prosthesis to a maximum of 1 single or 1 double prosthesis every 2 80% 80% benefit years Stump Socks to a maximum of 5 pairs per person per benefit year Support Stockings to a maximum of 2 pairs per person per benefit year Custom-made Orthotics to 10

maximum of $500 per person per 3 benefit years Custom-made Orthopaedic Shoes to a maximum of 2 pairs per person per benefit year Hearing Aids to a maximum of $1,000 per person per 4 benefit years Glucometers to a lifetime maximum of $700 per person Insulin Infusion Pumps to a maximum of $3,500 per person per 5 benefit years Out of Canada Emergency 100% Subject to a lifetime maximum of $3,000,000 for members under age 70 and their dependents. Subject to a lifetime maximum of $500,000 for members over age 70 and their dependents. Subject to a lifetime maximum of $500,000 for members (and their dependents) who transferred from the Core-Plus Plan after January 1, 2014 due to reduced work hours at age 55 or older. Referred Services 80% to a lifetime maximum of $50,000 Vision (only after cataract Covers initial par of surgery) eyeglasses at 80% Eye Exams 80% up to a maximum of $80 every 24 months for adults and every 12 months for dependent children 100% to a lifetime maximum of $3,000,000 per person up to age 70 80% to a lifetime maximum of $50,000 Covers initial par of eyeglasses at 80% 80% up to a maximum of $80 every 24 months for adults and every 12 months for dependent children Termination: For Medical Office Staff, coverage will end the first day of the month following the date the employee retire, or reaches age 65, whichever is earlier. However, coverage can be continued until age 70, provided that you continue to be actively working for your employer at least 20 hours a week and you continue to meet all of the eligibility requirements. 11

Dental Care Physicians Under Age 70 Medical Office Staff Annual Deductible $50/Single & $100/Family $50/Single & $100/Family Maximums (Preventative, Basic and Major Services) The maximum for members under age 70 and their dependents is $2,000 per benefit year per person. Orthodontic Maximum Preventative Dental Services Oral Examinations o 1 complete exam every 36 months o 1 recall exam every 9 months o Emergency or specific exams -rays o 1 complete series of x-rays or 1 panorex every 36 months o 1 set of bitewing x- o rays every 9 months -rays to diagnose a symptom or examing progress of a course of treatment Other Services o o Required consultations between two dentists polishing & topical fluoride treatment The maximum for members over age 70 and their dependents is $1,000 per benefit year per person. The maximum for members (and their dependents) who transferred from the Core Plus Plan after January 1, 2014 due to reduced work hours at age 55 or older is $1,000 per benefit year per person. $2,000 per eligible dependent child per lifetime for members up to age 70 $2,000 per person per benefit year $2,000 per eligible dependent child per lifetime 80% 80% 12

o o o o o o once every 9 months Emergency or palliative services Diagnostic tests & lab exams Removal of impacted teeth Provision of space maintainers for missing primary teeth pit & fissure sealants Oral hygiene instruction once per lifetime for children under age 19 Basic Dental Services Fillings Extractions Basic Restorations Endodontics Periodontics (scaling & root planing to a combined maximum of 8 units per benefit year Oral Surgery Repair Rebase or reline Major Dental Services Major restorations Prosthodontics Orthodontic Services Available for dependent children under age 19 of members under the age of 70 80% 80% 60% 60% 50% 50% Termination: For Medical Office Staff, coverage will end the first day of the month following the date the employee retire, or reaches age 65, whichever is earlier. However, coverage can be continued until age 70, provided that you continue to be actively working for your employer at least 20 hours a week and you continue to meet all of the eligibility requirements. 13

How to Submit a Claim Type of Claim* Pay Direct Drug Card 14 Electronically by Provider Sun Life Website Paper Claim Life Accidental Death and Dismemberment** Long Term Disability Prescription Drugs Dental Procedures Acupuncturist Chiropractor Massage Therapist Naturopath Osteopath Physiotherapist Podiatrist Psychologist Speech Therapist Hospital Private Duty Nursing Medical Equipment/Aids Wigs Foot Orthotics Orthopedic Shoes Hearing Aids Eye Exams * Not all expenses covered by this plan are listed above. Please contact Sun Life claims department for all claims enquiries - 1 800 361 6212 ** The Accidental Death and Dismemberment benefit is provided by Industrial Alliance Insurance and Financial Services Inc. All other benefits are provided by Sun Life. Pay Direct Drug Card: All new enrollees to the plan are issued a Pay Direct Drug Card. Present your pay-direct drug card at your pharmacy for immediate claim adjudication and reimbursement. If you require a replacement card please contact Sun Life claims department directly on 1 800 361 6212. Electronically by the provider: In order for your dental office to submit a claim electronically to Sun Life you will need to provide your Group/contract number and certificate/member ID number. Please contact your plan administrator for this information if necessary. If your dentist is not able to submit claims electronically, attach your original receipts (keeping photocopies for your records) to a Sun Life Dental Claim form, and submit to the postal address on the form. Sun Life Website: To access the Sun Life website you will need an Access ID and password. These can be retrieved on-line or by phone. You will need to provide the following information: Some personal information

Your contract or policy number Your certificate or member ID number Register on-line: https://www.sunnet.sunlife.com/registration/register.wca Register by phone 1 877 SUN-LIFE (1-877-786-5433) Monday to Friday 8 a.m. to 8 p.m. ET Once you have your access ID and password, go to www.mysunlife.ca and sign in! Paper Claim: For Life, Accidental Death and Dismemberment or Long Term Disability claims contact the Insurance Administrator at Doctors of BC to receive the necessary claim forms. Extended Health and Dental claim forms can be found on the Doctors of BC web site at https://www.doctorsofbc.ca/member-area/insurance/health-dental-plan or by clicking on the following links: Health Claim Form Dental Claim Form 15

Optional Cost-Plus Benefit In order to be eligible to claim under the Cost Plus portion of the Plan, expenses must be recognized as eligible medical expenses under the Income Tax Act. For more information about the types of expenses that are covered, refer to Eligible medical expenses on Canada Revenue Agency (CRA) website (http://www.cra-arc.gc.ca) or contact your professional tax advisor and/or CRA. The benefit year is the calendar year from January 1 to December 31. Eligible expenses are limited to the maximum amount payable per participant and their dependent(s) per benefit year, which is established prior to enrollment in the Plan. Medical expenses that are not eligible under the Income Tax Act and therefore not eligible under the Cost Plus plan include: athletic or fitness club fees; birth control devices (non-prescription); blood pressure monitors; cosmetic surgery - expenses for purely cosmetic procedures including any related services and other expenses such as travel, incurred after March 4, 2010, cannot be claimed as medical expenses. Both surgical and non-surgical procedures purely aimed at enhancing one's appearance are not eligible. These non-eligible expenses include the following: o liposuction; o hair replacement procedures; o filler injections (for removing wrinkles); o teeth whitening An expense, including those identified above, may qualify as a medical expense if it is necessary for medical or reconstructive purposes, such as surgery to address a deformity related to a congenital abnormality, a personal injury resulting from an accident or trauma, or a disfiguring disease. diaper services; health plan premiums paid by an employer and not included in your income; health programs; organic food; over-the-counter medications, vitamins, and supplements, even if prescribed by a medical practitioner; personal response systems such as Lifeline and Health Line Services; the following provincial and territorial plans: o Alberta Health Care Insurance Plan o Manitoba Health Plan o Medical Services Plan of British Columbia o New Brunswick Medicare Division of Provincial Department of Health o Newfoundland Medical Care Plan 16

o Northwest Territories Health Insurance Services Agency of Territorial Government o Nova Scotia Medical Services Insurance o Nunavut Health Care Plan o Ontario Health Insurance Plan o Prince Edward Island Health Services Payment Plan o Quebec Health Insurance Board (including payments made to the Health Services Fund) o Saskatchewan Medical Care Insurance Plan o Yukon Territorial Insurance Commission; or travel expenses for which you can get reimbursed. 17

Cost Plus Claims Process Member 1. Member has eligible health expense 5. Submit remaining expense to cost plus 7. Doctors of BC deposits amount of expense directly in member s bank account Doctors Doctors of BC of BC Cost Plus 2. Submit receipts to Sun Life 3. Sun Life reimburses member according to plan design 6. Doctors of BC withdraws amount of expense + 7% admin fee from corporation Sun Life Medical Corporation 1. Member has eligible health expense Example: $2000 paid directly to dentist for dental expenses 2. Member submits receipts directly to Sun Life through web or paper claim process 3. Sunlife reimburses the member according to plan design Example: 80% of $2000 = $1600 4. (optional) member submits remaining expense to spouse s plan, which reimburses member according to plan design 5. Member submits remaining expense to BCMA cost plus plan through member website Example: submit $400 to BCMA ($2000-$1600 reimbursed by Sun Life) 6. Doctors of BC withdraws amount of expense + 7% admin fee from member s corporation Example: $428 is withdrawn ($400 + 7% of $400) 7. Doctors of BC deposits amount of expense directly in member s bank account Example: $400 is deposited into member s personal bank account 18

Result: Member has been fully reimbursed for personal medical expenses. Example: Member received $1600 from Sun Life and $400 through Cost Plus Corporation now has a tax-deductible premium expense for employee health benefits Example: Corporation has a $428 business expense for employee health premiums For instructions on submitting Cost Plus claims please refer to the Cost Plus Claim Guide. 19

Coordination of Benefits If your spouse also has a benefit plan, you may be able to submit your extended health and dental receipts to both plans and get up to 100% of your eligible expenses reimbursed. Insurance industry guidelines determine where to send claims first to the HBTF plan or to your spouse s program. The order is important! Here s why After submitting your receipts to the first program, you will receive a Claims Statement. Next, submit the Claim Statement along with a new claim form and photocopies of receipts to the second program to claim the balance of your expense. Follow the insurance industry guidelines below:» Your claims: Submit your claims to your HBTF extended health and dental plans first. Your spouse must then submit an extended health claim form to his/her program to be reimbursed for the balance of your claim.» Your spouse s claims: Submit claims to your spouse s program first. You will then submit an extended health claim form (to your program) for the balance of your spouse s claims.» Your children s claims: If your birthday is earlier in the calendar year than that of your spouse, you will submit your children s claims to your program first. If your spouse s birthday is first in the calendar year, s/he will submit claims to his/her program first. For example, if your spouse s birthday is July 18 and your birthday is November 18, then any expenses incurred by your children should be submitted to your spouse s program first. If your birthday is the same as your spouse s, then any expenses for your children should be submitted to the plan of the parent whose first name begins with the earlier letter in the alphabet. Note if your spouse s plan also includes a pay direct drug card, drug claims will be coordinated at the pharmacy and no additional forms will need to be completed. 20