Region of Peel Ontario Works Discretionary and Mandatory Vision Care Plan (10/2016) Table of Contents Introduction... 2 Instruction Guide for the Discretionary Vision Care Plan (Adults)... 3 The Adult Discretionary Vision Care Plan... 3 Who is covered?... 3 What is covered?... 3 Routine Eye Examination fees... 3 What does the client need to give to the provider?... 3 What policy plan # is used??... 4 Instruction Guide for the Mandatory Vision Care Plan (Children) 4 The Mandatory Vision Care Plan (children under 18). 4 Introduction... 4 Who is covered?... 4 What is covered?... 4 Routine Eye Examination Fees..5 What policy plan # is used??... 5 Important Facts... 5 Information you must gather... 6 What if they don t have their statement?... 6 Submitting a Claim 7 Contact Information for GWL... 7 Appendix I - Adult Fee Schedule... 8 Limitations... 8 Special Circumstances... 9 Appendix II Children under 18 Fee Schedule... 10 Limitations... 10 Special Circumstances... 11 Extenuating circumstances... 11 Additional Information... 12 Benefit provisions... 12 Coverage Verification... 12 Fee Schedule... 12 Reimbursement Level... 12 Co-ordination of Benefits... 12 Effective Date of Coverage... 13 Termination of Coverage... 13 Claims Submissions... 13 Reconsideration for claims denied by GWL... 14 Inquiries... 14 1
Introduction Great West Life Assurance Company (GWL) administers the mandatory and adult discretionary vision care plan on behalf of Ontario Works in Peel. Vision care providers requesting information regarding client eligibility or coverage should contact GWL directly at 1-800-957-9777 (for service providers only).
Instruction Guide for the Discretionary Vision Care Plan (Adults) The Adult Discretionary Vision Care Plan Coverage under this plan is for eyeglasses, including lenses and frames, repairs or replacement when: It has been prescribed by a qualified practitioner; or There has been a significant change in the prescription; or A repair/replacement to the lenses or frames is required. Who is covered? The following Ontario Works clients are covered for vision care services: An applicant/head of household who is receiving Ontario Works assistance; and Their spouse; and/or Their dependent children who are 18 years of age and older; or An 18 year old youth receiving assistance in their own right; or Dependent adults 18 years of age or older receiving Ontario Works assistance and whose parents are receiving assistance from the Ontario Disability Support Program (ODSP). What is covered? Services/products and fees are listed in the Ontario Works Vision Care Services/Products and Fee Schedule (Appendix I). Routine Eye Examination fees If you are between the ages of 20-64, Ontario Works will cover the costs for routine eye exams once every 24 months. Clients aged 20 to 64 years with medical conditions affecting the eye can receive a regular eye examination once every 12 months. What does the client need to give to the provider? The provider should be given the following information: Health Card; and Statement of Assistance. If the client does not have a Health Card or is not covered by OHIP then the Statement of Assistance is enough. 3
What policy plan # is used?? When submitting a claim for an adult Ontario Works client to GWL use Ontario Works in Peel Plan #51616 (for adults only). This policy plan number is used when: The client resides in Peel; and Is receiving Ontario Works assistance in Peel. The Ministry of Health and Long Term Care (MOHLTC) will administer the claims/payment process for eligible Ontario Works clients, and the cost will be covered 100% by the Province. Instruction Guide for the Mandatory Vision Care Plan (Children under 18) Introduction The Mandatory Vision Care Plan Coverage under this plan is for eyeglasses, including lenses and frames, repairs or replacement when: It has been prescribed by a qualified practitioner; or There has been a significant change in the prescription; or A repair to the lenses or frames is required. Who is covered? Coverage is provided for: Dependent children (under the age of 18) of eligible Ontario Works clients; or Children in Temporary care; or A youth 16 or 17 years of age eligible for Ontario Works in their own right; and An 18 year old in the month of their 18 th birthday. The 1 st month following a youth s 18 th birthday they are eligible for vision care services under the Ontario Works discretionary vision care plan. What is covered? Services/products and fees are listed in the Ontario Works mandatory vision care services/products and fee schedule (Appendix II). 4
Routine Eye Examination Fees Eye examinations are covered by OHIP once per year for persons under the age of 20. The provider should be given the following information oh behalf of the child: Health Card; and Statement of Assistance. If the client does not have a Health Card or is not covered by OHIP then the Statement of Assistance is enough. What policy plan # is used?? When submitting a claim for a dependent child to GWL use Ontario Works in Peel Plan #51607 (for children only). This policy plan number is used when: The client resides in Peel; and Is receiving Ontario Works assistance in Peel. The Ministry of Health and Long Term Care (MOHLTC) will administer the claims/payment process for eligible Ontario Works clients, and the cost will be covered 100% by the Province. I m a provider what do I need to know? Important Facts What do you need to do when an Ontario Works client and/or their dependent is seeking vision care from you? For eligible Ontario Works you should: Refer to Appendix I for adult discretionary vision care services/products and fee schedule; or Refer to Appendix II for Mandatory Vision Care Services/Products and Fee Schedule (for children under the age of 18) Refer to the Plan for all other important information Obtain a verification/confirmation # from GWL prior to services being rendered 5
Information you must gather The following information is required when you are submitting a claim: A copy of the client s Statement of Assistance; The applicant/head of household s 9 digit Member ID# which is indicated on the Statement of Assistance, and The Statement of Assistance in the period covered box must reflect the dates of the current month e.g. 010713 to 310713; The applicant/head of household s first and last name and their date of birth; The name and date of birth of the family member/patient who received treatment; and The patient s relationship to the applicant/head of household; The required GWL vision care claim form and submit to GWL within 90 days of services being rendered. What if they don t have their statement? The vision care provider must ensure they have the following information: The applicant/head of household s 9 digit Member ID #; and The client s first and last name; Their date of birth; The name and date of birth of the family member who received treatment; and Their relationship to the applicant/head of household; Verify with GWL that the client is currently eligible for assistance. Submitting a Claim You will submit a claim directly to GWL. You must ensure to: Obtain a verification/confirmation # from GWL prior to services being rendered Submit the claim using a Regional Municipality of Peel Mandatory and Discretionary vision care benefits claim form Submit the claim electronically or by mail directly to GWL Submit the claims within 90 days of services being rendered Claim forms may be obtained by contacting Great West Life at 1-800-957-9777 or on the Region of Peel s web site http://www.peelregion.ca/ow/partners/ Requests to extend a claim beyond the 90 days must be submitted directly to GWL in writing providing the reasons for the extension. 6
Contact Information for GWL Contact information for GWL is: Claims sent by mail: The Great West Life Assurance Company London Benefit Payments 255 Dufferin Ave. London, ON N6A 4K1 Telephone inquiries: 1-800-957-9777 ( for providers only) 7
APPENDIX I Adult Discretionary Vision Care Services/Products and Fee Schedule Service/Products and Fee Schedule Verification or confirmation # is required from GWL prior to services being rendered. Great West Life may reimburse the provider the cost for the following products: Item Amount Single vision lenses and frames up to $100.00 or Bifocal lenses and frames up to $130.00 or, Trifocal lenses and frames up to $180.00 or, Contact lenses up to $180.00 Replacement lenses and frames up to $80.00 Limitations Item Standard Benefits Lenses and Frames Change in Prescription Replacement, Repairs or Loss Details Clients are entitled to one pair of frames and lenses every three years. There may be limitations with choosing bifocal lenses. The lenses required are usually dictated by the prescription. Lenses and frames are provided, subject to a maximum amount (see fees). A client may choose more expenses lenses (add on features) or frames and pay the difference in cost including the difference in dispensing fee directly to the supplier. In cases where the item is a medical necessity, it may be authorized (see Special Lenses/Frames). If there has been a significant change in the client s prescription, the client may obtain a new pair of lenses once prior to the end of the 3 year period. Proof of the need for repairs (e.g. broken glasses) is required. Clients may receive replacement lenses and/or frames once in a three year period but are subject to the maximum (see fees). The cost to replace/repair lenses or frames cannot exceed the cost to purchase a new pair of glasses. 8
Special Circumstances Item Details Special Lenses and/or Frames Contact Lenses Some clients may have special requirements or needs (e.g. special frames and/or lenses) for medical reasons. The item or service may be authorized after receiving documentation from the prescribing ophthalmologist, optometrist or general practitioner explaining the medical necessity of the service or item. In situations where contact lenses are considered a medical necessity, written medical rationale along with the prescription, are to be submitted to Great West Life for consideration. Medical necessity includes, but is not limited to the following conditions: Aphakia (post cataract surgery); Corneal abnormalities; Astigmatism (inadequately corrected by eyeglasses); High refractive error where the error is great than 8 diopters; Anisiometropia. Extenuating Circumstances Ontario Works in Peel will consider coverage required due to other extenuating medical situations not mentioned above and which special lenses/frames/contact lenses are deemed a medical necessity. Written medical rational substantiating the requirement must be submitted to Great West Life for consideration. 9
APPENDIX II Mandatory Vision Care Services/ Products and Fee Schedule (for children under the age of 18) Service/Products and Fee Schedule Verification or confirmation # is required from GWL prior to services being rendered. Great West Life may reimburse the provider the cost for the following products: Item Amount Single vision lenses 100% of cost or, Bifocal lenses 100% of cost or, Trifocal lenses 100% of cost or, Frames up to $100.00 Contact Lenses 100% of Cost (see limitations) Special lenses/frames 100% of Cost (see limitations) Replacement lenses As above Replacement frames As above Limitations Item Standard Benefits Lenses Frames Replacement Lenses due to a change in prescription Replacement due to loss, damage, negligence Details Children can receive a new pair of lenses or frames every three years The lenses are usually dictated by the prescription so there may be limited choices. If more expensive lenses are chosen because of add ons (e.g. tints, photo gray) they can pay the difference in cost, including the difference in the dispensing fee directly to the supplier. It may be authorized if the item is required because of a medical necessity. (see special lenses/frames) Frames are provided subject to a maximum amount (see fees). The beneficiary may choose a more expensive frame and pay the difference in cost directly to the supplier. Children can receive new lenses anytime there is a change in prescription. The new lenses should be placed in existing frames where possible. Children may receive replacement lenses and/or frames as needed without restrictions; however cases are subject to review where appropriate (e.g. excessive requests). 10
Repairs Proof of the need for repairs (e.g. broken glasses) is required. If GWL approves the repair, glasses can be repaired in cases where the cost of repairs will not exceed the cost of replacement. Special Circumstances Item Details Special Lenses and/or Frames Contact Lenses Some children may have special requirements or need due to medical reasons, the item or service may be authorized after receiving documentation form the prescribing ophthalmologist, optometrist or general practitioner explaining the necessity of the service or item. In situations where contact lenses are considered a medical necessity, written clinical rationale along with the prescription, are to be submitted to GWL for consideration. Medical necessity includes the following conditions: Aphakia (post cataract surgery); Corneal abnormalities; Astigmatism (inadequately corrected by eyeglasses); High refractive error where the error is great than 8 diopters; Anisiometropia Extenuating circumstances Ontario Works in Peel will consider coverage required due to other extenuating medical situations not mentioned above and which special lenses/frames/contact lenses are deemed a medical necessity. Written medical rational substantiating the requirement must be submitted to Great West Life for consideration. 11
Additional Information Benefit provisions Coverage is provided for the products listed in the OW in Peel s Schedule of Services and Fees (Appendix I and II). If the client requires vision care services, which are not authorized in the OW in Peel s Schedule of Services and Fees, or fees exceed the maximums as outlined the vision care provider may proceed with work only if the client agrees to pay the provider directly for services not covered or the difference in cost of services covered. Coverage Verification Coverage is limited to the services described in the Schedule of Services and Fees (Appendix I and II). The information in this section will help determine whether or not the services will be covered. If the service is not listed, then the product or service is not covered and coverage will not be approved. If the client requires vision care services, which are not authorized in the OW in Peel s Schedule of Services and Fees, or fees exceed the maximums as outlined the vision care provider may proceed with work only if the client agrees to pay the provider directly for services not covered or the difference in cost of services covered. Fee Schedule Coverage Provision Vision Care Services and Fees are limited to the listed products and fees are limited to the listed products and fees as outlined in the OW in Peel s Fee guide. Any other services/products required that are not listed will be at the client s expense. Vision care providers must obtain verification or confirmation # from GWL prior to services being rendered. Reimbursement Level 100% as per the Ontario Works in Peel s Fee Schedule. Co-ordination of Benefits Benefits may be co-ordinated through this plan. Claims for services performed for patients who have vision care benefits under a private plan, contract or insurance policy must be submitted through the private plan first. OW coverage is the second payor if the amount paid by the first payor is less than this schedule or if the first payor declines payment. 12
Effective Date of Coverage Coverage takes effect on the date the person became eligible to receive OW assistance. Termination of Coverage Coverage for client end on the earlier of the following dates: 1. The date this program ends; and 2. The last day of the month in which the OW benefits cease 3. In the month a dependent turns 18 they continue to receive vision coverage under the mandatory fee guide. The 1 st month after a dependents 18 th birthday they receive coverage for vision care services under the discretionary fee guide. Claims Submissions This program is for all eligible claims incurred on or after August 1, 1999. All claims for discretionary and mandatory vision care services/products are to be submitted to GWL using a Regional Municipality of Peel Mandatory and Discretionary claim form. This form is available online at this location: http://www.peelregion.ca/ow/quicklinks/forms-pdf/dental-form.pdf You can also contact GWL at 1-800-957-9777. This claim form has been customized to include the group policy number(s). The client s information must be completed in full. Once the claim form has been completed with both the vision care provider s and client s, spouse, guardian and/or dependent child 18 years of age or older signature the form can be sent to GWL Assurance Company for processing. In all cases, benefits will be paid directly to the provider of service, not to the client. In order for vision care providers to receive payment, the client who requires the service must sign the claim form. The signature of the client, spouse, guardian and or dependent child 18 and over who is an eligible member in the benefit unit is an acknowledgement of services rendered. IMPORTANT: Claims must be received by GWL Assurance Company within 90 days of the services being rendered; otherwise, it cannot be guaranteed that benefits will be considered. Claim forms not completed correctly will be returned to the service provider and must be re-submitted within the 90-day time limit. Requests to extend a claim beyond the 90 days must be submitted to GWL in writing providing the reasons for the extension. 13
Reconsideration for claims denied by GWL If a claim has been denied by GWL a provider may submit a request to OW for reconsideration of the claim. The following information must be provided: Reasons for reconsideration; The Claimant s Explanation of Benefits/Denial letter from GWL; Applicant s member ID#, applicant s name, patient s member ID# and name; Providers name, phone # and address Requests for reconsideration of claims denied by GWL may be granted on a case by case basis. Requests for payments because of the difference in costs paid by GWL and the actual cost charged by the vision care provider will not be considered. Requests must be submitted to: Client Relationships Vision Care Appeals 10 Peel Centre Dr., Suite B PO Box 2700, STN B Brampton, Ontario L6T 0E6 Once a decision to deny a claim has been made by Ontario Works in Peel, the decision is final. Inquiries All inquiries should be directed to GWL prior to contacting Ontario Works. Please contact Great West Life at 1-800-957-9777or by mail: The Great West Life Assurance Company London Benefit Payments 255 Dufferin Ave. London, ON N6A 4K1 After contacting GWL, Vision Care service providers may also direct their inquiries to Ontario Works via email at: ZZG-OW Dental-Vision Request@peelregion.ca or to speak to someone directly call extension (905) 793-9200 ext 8453. Inquiries should include the following information: Member ID # of the applicant and their first and last name; The name of the person who required the dental work; and The name of the dental provider and their phone #; and The reasons for the inquiry 14