Calgary Fire Department Pensioners Association

Transcription

1 Group Medical Services Calgary Fire Department Pensioners Association CFDPA Group Benefit Plan # Open Enrollment period August 1 st October 31st, 2014 Transfer from other plans (with medical and dental) at any time in the future within 60 days to join without medical clearance and questionnaire Group Medical Services is the operating name for GMS Insurance Inc. looking after you and the ones you love

2 SCHEDULE OF PREMIUMS: Benefit Premium Rate Health & Dental with Travel Coverage for all trips up to 60 days Single $77.60 Couple $ Family $ RATE GUARANTEES: Benefit Guarantee Extended Health Care and Dental Care 12 Months to July 31, 2015 Subsequent renewal rates are guaranteed 12 months for all benefits. Our renewal date is August 1 st every year and as health, dental, prescription, and travel costs increase every year it is likely there will be an inflationary increase every year. Other factors such as plan usage and changes to coverage will also affect rates. The value of the Canadian dollar also has an impact on travel coverage. PLAN BENEFIT PROVISIONS: GMS policy provisions and adjudication procedures will apply, unless otherwise stated below. Benefits will be adjudicated on the basis of the group s policy year, unless otherwise stated. Provision Limitation Comments a resident in Canada To apply as a participant, you must be retired from employment Eligibility Requirements covered by a provincial or of the City of Calgary Fire Department and related departments territorial government health (ie. Dispatch), or a spouse of same, and a member in good insurance plan standing of CFDPA. Termination of benefits Termination of membership Benefits cease upon termination of membership. Survivor benefit Up to 6 months Premiums waived. Dependent coverage 21/25 Up to age 21 or 25 if in full time post-secondary To be eligible for coverage as an overage dependant, student Student eligibility Institution within Canada must be undergoing full-time educational training, subject to the stated limitation. Pay-direct drug card Included. Prescription deductible is equal to the dispensing fee. Annual benefit maximum Emergency Travel Unlimited. 60 days per trip. $2,000,000 per person per policy year. 1 ST dollar pooling.(with all GMS group travel plans) IN CANADA HEALTH BENEFITS ARE PAYABLE TO A COMBINED MAXIMUM OF $10,000 PER PERSON PER POLICY YEAR. When eligible expenses are incurred outside of a Member s province of residence, GMS will cover the Reasonable and Customary charges for the following benefits, in excess of the amount permitted and/or paid by the government health insurance plan and/or any other insurance plans. IN CANADA HEALTH BENEFITS * Please note some benefit provisions may be limited to within the Member s province of residence. Calgary Fire Department Pensioners Association Page 2 of 8

3 ENROLLMENT GUIDELINES: All members within the Association will have a common anniversary date and all effective dates will be the first of the month. Proof of membership will be required for enrolment and the Plan Administrator of the Association is responsible for verification of membership and monitoring. Members are eligible to participate provided they are retired from employment of the City of Calgary. Spouses of Members (as well as Spouses of Deceased members) insured under this Plan may be covered. Children, stepchildren or adopted children of Members insured under this Plan may also be covered if they are unmarried, dependent on the Member for support, and at least 15 days old but not yet 21 years old (or not yet 25 years old if they are in full time attendance at an accredited educational institution, college or university). Original enrolment forms must be signed and can be mailed, scanned, faxed or dropped off to Puhl Employee Benefits Inc - # Midpark Way SE Calgary, AB T2X 1M2 All plan members must be set up for Pre-Authorized Debit (PAD) and a PAD agreement with banking info and/or void cheque for monthly withdrawals must accompany enrolment forms. Plan design changes will be implemented on renewal only and are to encompass the entire Association. **** Evidence of Insurability will be required for members after Open Enrollment period or when joining after more than 60 days without another Medical and Dental plan **** Medical evidence is required from Members and/or their dependents if enrolling in the program after the specified open enrollment period or not transferring from another health and dental plan with 60 days of termination in the previous plan. Coverage on Members and/or their dependents who were required to provide medical evidence, would be effective on the day of the month the evidence of insurability was accepted by Group Medical Services. Members and/or dependents who enrol in the dental benefits plan after the specified open enrollment period will be limited to a maximum of $ during the first 12 months of coverage.. UNIQUE PLAN BENEFITS: The following plan benefits are included at no extra charge: For return ambulance we cover 50% return of a bedridden patient to their place of residence Calgary Fire Department Pensioners Association Page 3 of 8

4 Drugs Plan Benefit Details: HEALTH AND TRAVEL COVERAGE DETAILS HEALTH PROVISION DESCRIPTION MAXIMUM NOTES 80% reimbursement. Prescription deductible is equal to the dispensing fee. $1,500 per Insured Person per Drugs which by law, requires a Standard restrictions written prescription. apply. Formulary and non-formulary. Vision Ambulance Excludes: Eye examinations. 50% return for bedridden cases. Glasses/Contacts/Laser Eye Surgery - $200 per 2 Policy Years, including the current Unlimited. Air Ambulance $4,000 per year. Private Duty Nursing In-hospital and in-home nursing. Preferred Wards Unlimited. $2,500 per authorization Accidental Dental $2,000 per injury. Practitioners Includes: Acupuncturist, chiropractor, massage therapist, naturopath, speech therapist, physiotherapist and psychologist. Cast/Crutch Unlimited. Patient Walkers Artificial Prosthesis Wheelchair/ Motorized Scooters/ Beds Diabetic Ostomy Supplies Oxygen Equipment Breast Prosthesis Custom Foot Orthotics Therapeutic Shoes Rental or, when approved by GMS, purchase. Rental or, when approved by GMS, purchase. Rental or, when approved by GMS, purchase. GMS standard requirements. GMS standard requirements. Combined maximum of $300 per Insured Person per $200 per family, per 3 Policy Years, including the current Policy Year. $10,000 lifetime maximum, per Insured Person. $500 per family, per 5 Policy Years, including the current Policy Year. $300 per Insured Person per $300 per Insured Person per $500 per Insured Person per (incl. CPAP related) 1 if lateral/2 if bilateral, per 2 Policy Years including the current Policy Year. Adults 1 pair per 5 Policy Years. Dependants (16 years of age and under) 1 per $200 per Insured Person per required for massage, physiotherapist and psychologist, each authorization authorization referral required for bilateral mastectomy patients. authorization authorization, including medical diagnosis is Calgary Fire Department Pensioners Association Page 4 of 8

5 Hearing Aids OOP Referral (Within Canada) Additional Benefits Emergency Travel Referral outside your Province of Residence for medical treatment, which is not available in your Province of Residence. Requires GMS approval. Rental or purchase. Splints, wigs, braces with metal components, trusses, rib belts, air casts, clavicle straps, cervical collars, shoulder immobilizers, sacroiliac corsets, embolic stockings, aero chambers and compressors. 60 days per trip. Includes Hospitalization, Physicians and Surgeons, Health Practitioners, Private Duty Nursing, Emergency Transport, In-Flight Medical Attendant, Accidental Injury to Natural Teeth, Prescription Drugs, Return of Remains, Vehicle Return and 24-hr Travel Assistance. $500 per Insured Person, per 3 Policy Years, including the current $50,000 Lifetime maximum, per Insured Person. $500 combined per Policy Year including the following: o Embolic (compression) stockings - 4 pairs per Policy Year. $2,000,000 per Insured Person per When fitted by an audiologist or when an audiogram is conducted by an audiologist. Each item requires a written Physician prescription. 1 st dollar pooling *** OUT-OF-PROVINCE/CANADA BENEFIT CONDITIONS AND EXCLUSIONS *** The following exclusions and limitations apply to travel outside of their Province of Residence and Canada. Coverage for medical conditions that existed prior to the departure date is subject to the following: This policy does not provide coverage for any expenses related directly or indirectly as a result of: For Members under the age of seventy-five (75) years: a) Your medical condition and/or related condition and/or symptoms (whether or not the diagnosis has been determined) if at any time in the hundred eighty (180) days preceding your departure date your medical conditions or related conditions and/or symptoms have not been stable; b) If at any time in the hundred eighty (180) days prior to your departure date: i) Any heart condition, has not been stable; ii) Any lung condition has not been stable. For Members seventy-five (75) years of age and older: a) Your medical condition and/or related condition and/or symptoms (whether or not the diagnosis has been determined) if at any time in the three hundred sixty five (365) days preceding your departure date your medical conditions or related conditions and/or symptoms have not been stable. b) If at any time in the three hundred sixty five (365) days prior to your departure date: i) Any heart condition, has not been stable; ii) Any lung condition has not been stable. Calgary Fire Department Pensioners Association Page 5 of 8

6 DENTAL COVERAGE DETAILS Provision Limitation Comments Late Applicant $250 If dental coverage is not selected within 31 days of becoming eligible, benefits will be limited to the stated limitation during the first 12 months of coverage On-line Dental Included Dental fee guide Current Benefits will be adjudicated based on the stated dental fee guide. Description Percentage Co-pay Maximum 80% reimbursement. Combined maximum of $1,000 per Insured Person per 50% reimbursement. Orthodontics Not included. Description Benefit Maximum Casts diagnostic Once per person per three (3) policy years, including the current policy year Interproximal Disking of Teeth Included Exams Complete Exams Limited oral Once per person per three (3) policy years, including the current policy year Recall/Specific Combined maximum of two (2) examinations per policy year Emergency Unlimited Fluoride Two (2) time units per person per policy year Caries Trauma/Pain control Included Restoration Amalgam Included Pins/Restoration Included Endodontics Denture Adjustments Once per person per policy year Denture Repairs Included Relining/Rebasing Denture Remakes Subject to a five (5) year limitation Bridge Repair Included Retainers Direct/indirect Included Extractions Included Root canal therapy is limited to one (1) per tooth per five (5) policy years, including the current policy year Once per person per three (3) policy years, including the current policy year, per arch Polishing Two (2) time units per person per policy year Scaling Ten (10) time units per policy year, combined with root planing Pit and Fissure Sealants Space Maintainers Protective Mouth Guard Appliances Perio Appliance Bruxism One (1) per tooth per lifetime for individuals under the age of eighteen (18) years One (1) per policy year for dependent children under sixteen (16) years of age, and one (1) per three (3) policy years, including the current policy year, for persons sixteen (16) years and over One (1) per policy year for dependent children under sixteen (16) years of age, and one (1) per three (3) policy years, including the current policy year, for adults Calgary Fire Department Pensioners Association Page 6 of 8

7 Tests Pulp Viability Included Treatment Plan/Consultation Included X-rays Periodontics Non-surgical Included Periodontics Surgical (Flap Approach) Fractures Treatment Included Complete Series/Panoramic One of either type per person per three (3) policy years, including the current policy year Intra-oral/Extra-oral Ten (10) films per person per two (2) policy years, including the current policy year Each type of surgery is limited to one (1) per site (sextant) per policy year Root Planing Ten (10) time units per policy year, combined with scaling Anaesthesia Included Chemo Agents Included Occlusal Adjustment and Equilibration Restoration Amalgam Cores Included Tooth Coloured Core Included Inlays/Onlays Posts Crowns Veneers Restorative Procedures Included Full Dentures Partial Dentures Bridges Retainers Plastic/Acrylic Included Retainers Porcelain/Ceramic Included Remodelling/Recontouring Included Consultations Professional Included Lab & Expense Procedures Included Combined maximum of four (4) time units per person per policy year Once per tooth per five (5) policy years Replacements must be separated by at least five (5) years Once per tooth per five (5) policy years Replacements must be separated by at least five (5) years Once per tooth per five (5) policy years Replacements must be separated by at least five (5) years Once per tooth per five (5) policy years Replacements must be separated by at least five (5) years Initial - Limited to teeth extracted while covered under this plan, to a maximum of one (1) per arch per five (5) policy years Replacement Limited to teeth extracted while covered under this plan, or provided the existing complete dentures are at least five (5) years old Initial - Limited to teeth extracted while covered under this plan, to a maximum of one (1) per arch per five (5) policy years Replacement Limited to teeth extracted while covered under this plan, or provided the existing partial dentures are at least five (5) years old Replacement bridge pontics and fixed bridge retainers on teeth extracted while covered under this plan, or provided the existing bridge pontic or fixed bridge retainer is at least five (5) years old Calgary Fire Department Pensioners Association Page 7 of 8

8 CONTACT INFORMATION (Group Medical Service) Calgary Agent PUHL EMPLOYEE BENEFITS INC. Meaghan Paterson or Shannon Magotiaux at CFDPA Administrator Contact - Doug Chern doug.chern@shaw.ca Mailing Address CFDPA Benefit Plan c/o Puhl Employees Benefits Inc. # Midpark Way SE Calgary, AB T2X 1M2 - Group Benefits - click My GMS or Login* *once you have joined and registered It is advisable to get pre-clearance for travel coverage if you are unsure or unclear about coverage. - TravelStar Travel top-up for single trips longer than 60 days Calgary Fire Department Pensioners Association Page 8 of 8