Contents of this Booklet

Transcription

1 Contents of this Booklet Your Benefits Support Team 2 Benefit Information Summary 3 Plans 3 Plan coverage options 4 Plan coverage summary 5 Plan 1& 2 Extended Health Care & Prescriptions Drug Coverage 6 Plan 65+ Extended Health Care & Prescriptions Drug Coverage 7 Plan 1 and 2 and Plan 65+ Care (Basic & Enhanced) 8 Page How to Enroll Forms to be included with your application 9 Cheques to be included with your application 10 Included in your Enrollment Package Envelope Benefit Information Booklet Health Care Providers Group Enrollment Form Form 1 Employee Group Health Form Application for Optional Group Life Insurance for Spouse Application for Optional Group Life Insurance for Children Form 2 - Statement of Health Rate Sheet monthly cost of Benefits Worksheet Request Form for Optional Life Insurance and/or Optional Employee Long Term Disability Postage Paid Envelope (checklist on back of envelope) Things to think about One Time 31 Day Offer Health Care Providers Group Insurance Plan Page 1

2 Your Benefits Support Team Marketed by: HARDIMAN MOUNT & ASSOCIATES INSURANCE BROKERS LTD. 500 Brock St. S. Whitby, ON L1N 4K7 Tel: (905) Fax: (905) Toll free: HMA Web site: HCP Web site: Administered by: TPA ADMINISTRATIVE SERVICES LTD. 299 Glenview Ave. Suite 201 Oshawa, ON L1J 3H5 Tel: (905) Toll free: Fax: (905) Underwritten by: THE CO-OPERATORS LIFE INSURANCE CO. & GREEN SHIELD CANADA Product Creation & Design: Barry Mount CLU Bob Morrow CLU, RHU, CEBS (consultant) Help is just a phone call away Hardiman, Mount & Associates Call us to go over the plan with you. We will explain any areas you are unsure about and also help you with your enrollment forms. TPA Administrative Services Once enrolled TPA will assist you with all your administrative changes. Call TPA with any changes re: banking, marital status, new address etc. and/or if you have any questions relating to submission of claims. Pick up the phone, we are here to help you. (all numbers are listed above) Health Care Providers Group Insurance Plan Page 2

3 Benefit information Summary 3 Plans Your average weekly hours worked and your age determine which plan is applicable to you (see chart below). Plans 1 and 2 give ALL Part Time and Casual Hospital employees an opportunity to obtain coverage for themselves and their families. Plan 2 gives ALL Hospital Retirees an opportunity for coverage if they retire before age 65. Plan 65+ gives ALL Part Time and Casual Hospital employees and ALL Hospital Retirees an opportunity for coverage after age 65. Effective date of coverage: The first of the month following approval, or as requested during an open window (see page 9) Eligibility Coverage Conversion, change, and termination of coverage PLAN 1 PLAN 2 PLAN 65+ 1) Part Time or Casual Hospital employee under age 65 who is currently working less than an average of 18hrs/week 2) Any Hospital employee, under age 65 who is leaving or retiring from the hospital, or has retired from the hospital Part Time or Casual Hospital employee under age 65, who is currently working an average of at least 18hrs/week Life, ADD&D, Disability Income, Health, Drugs, Travel, Hospital & Health, Drugs, Travel, Hospital, & Any Part Time, Casual or Full Time Hospital employee reaching age 65, currently working at the hospital, or has retired from the hospital Health, Drugs (enhanced option only), Travel, Hospital & On Plan 1 your Employee Life Insurance can be converted within 31 days of you leaving the hospital, retiring or when you reach age 65, whichever is the earliest. Your Employee Long Term Disability coverage will cease. Your coverage will change with a change in eligibility (see note on transfers below), and when you reach age 65 it will change to Plan 65+. You may continue to be enrolled on the plan when you leave the hospital, but please call TPA Administrative Services so they can make the necessary adjustments to your coverage and your premium. Your coverage will terminate if you become a Full Time employee, if you are no longer paying premiums, or if you decide to terminate the plan yourself. NOTE 1: Transfers between Plan 1 & Plan 2 To determine whether you fall under PLAN 1 or PLAN 2, look at the average hours that you work on a weekly basis. If the average hours are greater than 18 hrs, then you are eligible for PLAN 1, if not then you are eligible for PLAN 2. Once you are enrolled you should monitor your hours periodically. If you are consistently working (ie: sustaining) an average number of hours that would change your eligibility from the plan you enrolled in you need to notify TPA Administrative Services so your coverage and premium can be adjusted. NOTE 2: Plan 65+ (Age 65 rollover): If you are enrolled in PLAN 1 or PLAN 2 under the Basic or Enhanced Health Care Option and you reach age 65 your coverage will change to the Basic Health Care coverage on the PLAN 65+. You need to inform TPA Administrative Services prior to reaching age 65 so your coverage and premium can be adjusted. If your dependant is under 65 and covered under your HCP plan they will retain their existing coverage until they reach age 65, then they will be rolled over to the Basic Health coverage under the PLAN 65+. If you and/or your dependant wish to apply for the Enhanced Health Care Option, you can at any time by submitting health evidence on Form 2 Statement of Health. ALL PLAN OPTIONS AND COVERAGES ARE EXPLAINED IN THIS BOOKLET ON PAGES FOLLOWING Health Care Providers Group Insurance Plan Page 3

4 Plan Coverage Options Benefit information Summary (Cont.) Coverage Option PLAN 1 Employee Life, ADD&D & Long Term Disability (Only available on Plan 1) *1A Health Care with Drugs 1C Basic Enhanced 1E 1F PLAN 2 Employee Life, ADD&D & Long Term Disability (N/A - not available) 2C N/A Coverage Option Health Care with Drugs Basic Care Enhanced Care 2E N/A 2F N/A Coverage Option Basic Health Care No Drugs PLAN 65+ Enhanced Health Care with Drugs Basic Enhanced 65B 65C 65D 65E 65F 65G * PLAN 1 Option 1A This option is only available to employees who already have spousal coverage. ie: when your spouse already provides Health Care and/or Care coverage for you through their Group Plan. This option enables you to protect YOUR income in case of sickness or injury, something that your spouse cannot do through their plan. Health Care Providers Group Insurance Plan Page 4

5 Plan coverage summary PLAN 1 Benefit information Summary (Cont.) - Employee Life, ADD&D and Long Term Disability Income (are included in all Plan 1 options) Employee Life Insurance ($10,000) & Employee Accidental Death, Disease & Dismemberment ($10,000) - Evidence of health is required for medical underwriting purposes, unless in an Open Window (see page 9). - Your Life Insurance coverage ceases when you retire, leave the hospital or turn 65. This life insurance can be converted within 31 days of the earliest of these events. - If you are disabled and remain disabled for more than 6 months you will not have to pay for your Employee Life Insurance and Accidental Death, Disease & Dismemberment coverage for as long as you are disabled - as defined in the master policy. Employee Long Term Disability Income ($800 per month) - Evidence of health is required for medical underwriting purposes, unless in an Open Window (see page 9). - It starts paying after your Employment Insurance (EI) Disability payments cease (120 days) - It pays all the way to age 65, as long as you remain disabled as defined in the master policy. - Definition of Disability -- 2 year own occupation from date of disability; thereafter any occupation. - Payments from this plan are paid tax free. - Primary CPP/QPP offset (ie: payments received from CPP/QPP will reduce monthly benefit from this plan) - Pre-existing condition limitation 90days/90days/12 months - Your disability insurance coverage ceases when you retire, leave the hospital, turn 65, or transfer to Plan 2 - If you are disabled for more than 6 months you will not have to pay for your Employee Long Term Disability coverage for as long as you remain disabled - as defined in the master policy - Benefit Adjustment: Your benefit will be adjusted so that your total disability income from all sources will not exceed 85% of your pre-disability net income Optional Life Insurance and Optional Employee Long Term Disability Income (Only available on Plan 1) Optional Life Insurance (Employee) convertible - You can purchase optional life insurance in units of $10,000 to a maximum of $500,000 - Evidence of good health is required (complete Form 1 - Group Health Form in your enrollment package) Optional Life Insurance (Spouse and/or child) Spouse convertible, child non-convertible - You can purchase Optional life insurance for a spouse and/or child Spouse: in units of $10,000 to a maximum of $500,000 Child: in units of $5,000 to a maximum of $50,000 - Evidence of good health is required (complete the applicable Health Forms found in your enrollment package) Long Term Disability Income (Employee Only) - You can purchase additional long term disability income protection up to a total of 65% of your salary, to a maximum benefit of $2,500 a month (includes the $800 Basic coverage). - Evidence of good health is required (complete Form 1 - Group Health Form in your enrollment package) Use the Worksheet Request form for Optional Life & Disability in your enrollment package to help you calculate your additional monthly premium, then submit the worksheet with your application Health Care Providers Group Insurance Plan Page 5

6 Extended Health Care & Prescription Drugs ( Plan 1& 2) Complete Form 2 in your enrollment package when applying for Health Coverage Overall Maximum There is No Lifetime Maximum. (Annual Maximums as noted below) Deductible There is no deductible DESCRIPTION BASIC ENHANCED Coinsurance - Percentage the Insurer pays (subject to coverage maximums) 70% 100% Note: Out of Country Travel (Basic) and Drug (Enhanced) exceptions Pay Direct Drug Card - Benefits include drugs legally requiring a prescription by law, needles and syringes. Pay generic only unless otherwise indicated on the prescription. Benefits do not include medication for treatment of anti-obesity, smoking cessation, erectile dysfunction and fertility 70% Co-ins $1,000/yr max 90% Co-ins $10,000/yr max Out of Country Travel - $1,000,000 calendar year maximum (60 day max/trip) 100% Co-ins 100% Co-ins Hospital Accommodations - Semi-Private room in a public general hospital $150/day No Limit Private Duty Nursing - Services of a Registered Nurse (RN or RPN) $5,000/yr $5,000/yr Paramedical Services Physiotherapist, Psychologist, Speech Therapist Podiatrist Chiropodist Registered Massage Therapist Chiropractor Osteopath Naturopath Accupuncture Dietician Occupational Therapist $400/yr (per practitioner) $400/yr (combined) $500/yr (per practitioner) $500/yr (combined) $500/yr (combined) Vision - Prescription Eye glasses and/or contact lenses $100 / 2yrs $150 / 2yrs - Eye exams (applies only to adults ages inclusive) $65 / 2yrs $65 / 2yrs Audio - Standard hearing aids, repairs or replacement parts up to the stated maximum every 5yrs $300 $500 Accidental - accident to natural teeth, submit accident report asap $1,500/yr $2,500/yr Medical Items - eg: wheelchair, hospital bed, glucometer & lancets, catheter & ostomy supplies, orthotics, prosthetics, ventilator, pressure gradient stockings, etc.individual items are scaled to usual & customary limits Emergency Transportation - Land or air ambulance $1,500/yr $5,000/yr Medical Alert Bracelets $50/ 2yrs $50/ 2yrs Note: Coverage maximums stated above are per benefit year (except Travel), and apply to each insured (ie: each employee and each insured dependant separately) Health Care Providers Group Insurance Plan Page 6

7 Extended Health Care & Prescription Drugs ( Plan 65+) Complete Form 2 in your enrollment package when applying for Health Coverage Overall Maximum There is No Lifetime Maximum. (Annual Maximums as noted below) Deductible There is no deductible DESCRIPTION BASIC ENHANCED Coinsurance - Percentage the Insurer pays (subject to coverage maximums) 70% 80% Note: Out of Country Travel and Drug exceptions Pay Direct Drug Card (Provincial Plan provides Drug coverage at age 65) Benefits include drugs legally requiring a prescription by law, needles and syringes. Pay generic only unless otherwise indicated on the prescription. Benefits do not include medication for treatment of anti-obesity, smoking cessation, erectile dysfunction and fertility. NO DRUG COVERAGE ON BASIC 80% Co-ins $5,000/yr max $7.00 Dispensing Fee max Out of Country Travel - $1,000,000 calendar year maximum (60 day max/trip) 100% Co-ins 100% Co-ins Hospital Accommodations - Semi-Private room in a public general hospital 100% Co-ins $150/day 14 day/yr max 100% Co-ins No daily max 14 day/yr max Private Duty Nursing - Services of a Registered Nurse (RN or RPN) $2,500/24 mnth $2,500/yr Paramedical Services Physiotherapist, Psychologist, Speech Therapist $400/yr (per practitioner) $500/yr (per practitioner) Podiatrist $500/yr Chiropodist (combined) Registered Massage Therapist Chiropractor $400/yr $500/yr Osteopath (combined) (combined) Naturopath Accupuncture Dietician Occupational Therapist Vision - Prescription Eye glasses and/or contact lenses $100 / 2yrs $150 / 2yrs Audio - Standard hearing aids, repairs or replacement parts up to the stated maximum every 5yrs $300 $500 Accidental - accident to natural teeth, submit accident report asap $1,500/yr $2,500/yr Medical Items - eg: wheelchair, hospital bed, glucometer & lancets, catheter & ostomy supplies, orthotics, prosthetics, ventilator, pressure gradient stockings, etc.individual items are scaled to usual & customary limits Emergency Transportation - Land or air ambulance $1,500/yr $2,500/yr Medical Alert Bracelets $50/ 2yrs $50/ 2yrs Note: Coverage maximums stated above are per benefit year (except Travel), and apply to each insured (ie: each employee and each insured dependant separately) Health Care Providers Group Insurance Plan Page 7

8 Deductible There is no deductible Care (optional available on all plans) DESCRIPTION BASIC ENHANCED Overall Maximum in Year 1 $500 $500 Overall Maximum in Year 2 $750 $750 Overall Maximum in subsequent years $1,000 $1,000 o Coinsurance: (Percentage the insurer pays (subject to coverage maximums) Year 1 70% 80% Year 2 and subsequent years 80% 80% Endodontal and Periodontal Services 50% 80% Major Restorative Not covered 50% After the 36 th month on the plan subject to a max of $500 within the overall max of $1,000 above. Recall Exams: Once every 9 months Once every 9 months Fee Guide: Current Current Note: Coverage maximums stated above are per benefit year and apply to each insured (ie: each employee and each insured dependent separately) Summary of eligible services: - recall examinations once every 9 months - fillings, cleanings, scalings, examinations and polishing - extractions - endodontic treatment (root canal therapy) - periodontal treatment of diseased bones and gums - standard denture services - surgical services - general anaesthetic - major restorative services (Enhanced Plan only) - dentures: standard dentures including complete, immediate, transitional and partial dentures. - crowns: standard onlays or crown restorations (paid to full metal on molar) to restore diseased or accidentally injured natural teeth - bridges: standard bridges, including pontics, abutment retainers/crowns (paid to full metal on molar) on natural teeth - standard repair or recementing of crowns, onlays and bridge work on natural teeth Health Care Providers Group Insurance Plan Page 8

9 How to Enroll Forms to be included in your application All forms are included in your enrollment package or can be downloaded from the web site (Please read the forms carefully. If you have questions when filling out the forms please or call us at Hardiman Mount & Associates) FORM NAME Health Care Providers Group Enrollment Form FORM 1 Employees Group Health Form Application for Optional Group Life Insurance for Spouse and Child (separate forms) FORM 2 Statement of Health Form Worksheet Request Form for optional Life Insurance and Employee Long Term Disability Income One Time 31 Day Offer Form: (must be completed and authorized by Human Resources) INSTRUCTIONS ALL APPLICANTS need to complete the front and back of this form. Make sure you date and sign the form where indicated Employees complete both sides of this form if you are: a) applying for Plan 1, and you are not in an open window (see below) b) applying for optional Employee Life Insurance and/or optional Employee Long Term Disability Income Complete both sides of each form if you are applying for spouse and/or child Optional Life ALL APPLICANTS need to complete the front and back of this form to apply for Health Coverage Complete this worksheet if you are applying for Plan 1 and you are: a) applying for optional Life Insurance for yourself and/or your spouse and/or your children b) applying for optional Employee Long Term Disability Income over and above the basic benefit of $800 per month Only complete this form if you are a: - New Part Time or Casual Hire into the Hospital - Full Time employee transferring to Part Time or Casual - Full Time Employee retiring from active employment at the Hospital OPEN WINDOW a one time opportunity to receive GUARANTEED BASIC coverage There are open window opportunities for each of the following groups at specific times. Check the chart below to see if you qualify. During an open window BASIC coverage is guaranteed for you, your spouse and your eligible dependents. If you qualify under #3 or #4 in the chart below, your application must be received at Hardiman Mount & Associates within the 31 days following the occurrence to receive the Basic Coverage Guarantee. Health Care Providers Group Insurance Plan Page 9

10 How to Enroll (continued) 3 Cheques to be included with your application Void Cheque A void cheque is needed with your application. Your monthly premium will automatically be withdrawn from this Bank Account ON YOUR PAY DAY. Please write VOID across your blank cheque. Deposit Cheque Please current date your deposit cheque. The amount is to be equal to the monthly premium for the option you have chosen. It will be cashed right away and held on deposit. This deposit is needed because all insurance premiums are paid on the 1st of the month and your monthly payments may not be collected until after that date, as your withdrawal dates vary from month to month. If there are insufficient funds in your bank account when the automatic withdrawal is made, this deposit will be used to secure your protection under the plan. First Month Premium Cheque This first month s premium cheque is to be dated the first of the month you wish coverage to commence. (this can be the 1 st of the next month or the 1 st of the month following that). If underwriting approval is needed your coverage will not commence until the first of the month following approval. The amount of the cheque is the monthly premium for the Option you have chosen Note: If you are applying for optional Life Insurance for yourself and/or your spouse and children and/or you are applying for optional Employee Long Term Disability Income Please include your calculation worksheet provided in this enrollment package with your application. The additional monthly premium will be withdrawn automatically from your bank account once approval has been given. Do not include the additional premium with your application. ALL CHEQUES ARE MADE PAYABLE TO T.P.A. ADMINISTRATIVE SERVICES LTD. Forward all documents to: Hardiman Mount & Associates Insurance Brokcers Ltd. in the Postage Paid Envelope provided. Health Care Providers Group Insurance Plan Page 10