Frequently Asked Questions:
When joining a group benefits plan what coverage do I have to take?
All benefits, with the exception of Extended Health Care (EHC) and/or Dental Care (DE), but only if you have similar EHC and/or DE coverage through your spouse’s plan.
Who is considered an eligible dependent of an employee?
Legally married spouse, or common-law spouse of the same sex or opposite sex (double check policy for any time limit related to how long someone is common-law), and natural children, stepchildren, adopted children and any child the employee has legal guardianship or custody by order of the Court, and residing with the employee or spouse.
Can a dependent residing outside of Canada be covered?
No, not unless it is a dependent child who is attending school out side of country and who the insurance company has approved extension of coverage for.
Is there a maximum age limit for a child to be considered a dependent for coverage?
Standard limits are:
* Under age 21 in respect to children who are not in school full-time, or
* Under age 25 in respect to children who are in full-time attendance at an accredited school, college or university
Age limits do vary slightly from one plan to another, therefore always double check your benefits booklet.
Can coverage be extended for disabled children?
Yes, once a child reaches the maximum age (i.e. age 21) and they continue to be incapable of self-sustaining employment by reason of a permanent developmental or physical disability and are dependent on the employee for support and maintenance and provided satisfactory proof that the conditions specified above exist and are submitted to the insurance company with 31 days after the attainment of the maximum age limit.
Who is considered a late applicant?
Any employee and/or dependent/s applying for coverage later than 31 days from their date of eligibility. The 31-day limit also applies to adding on a benefit that may have been waived initially.
Can coverage be acquired once considered a late applicant?
When late in applying for coverage, medical evidence of insurability must be provided for the employee and any dependents, if applicable, and must be approved by the Insurance Company prior to any coverage being extended. The 31-day limit also applies to adding on a new dependent, or benefit/s that may have been waived initially.
What is a non-evidence maximum / no-evidence limit (NEM)?
This is the maximum amount of insurance (usually related to Life and/or Disability) that an eligible employee may be covered for before the Insurance Company will require that medical evidence of insurability, prescribed by and satisfactory to the Insurance Company, be submitted.
Does an employee have to apply for excess coverage over and above the non-evidence maximum (NEM)?
No, it is an employee’s option to apply for the excess coverage, plus they could apply at a later date should they choose to.
Is extra medical travel coverage needed if I have Travel Coverage under my group benefits plan?
No, it should not be necessary to purchase extra coverage.
Do I need to contact the Travel company before travelling?
If you have a concern due to a medical condition/problem or where you are travelling to, it is recommended that you call the Travel company prior to travelling. When travelling always carry your provincial health care card and your emergency travel assistance benefit card and contact the Travel Assistance company as soon as possible in the event of a medical emergency.
As well, before travelling to any foreign country, plan members should check the federal government’s Travel and Tourism website at www.travel.gc.ca and follow requirements accordingly.
Is there Trip Cancellation coverage included in Travel Coverage under a group benefits plan?
Most carriers do not offer trip cancellation insurance. Please check your policy for details.
If I have vision care coverage and were to purchase glasses off the internet would they be covered under my plan?
For purchases made at an eye clinic or on line, as long as you have the prescription and receipt, reimbursement would be processed as per your plan schedule.
Download the Detailed FAQ
Recent fee guides and claim requirements:
Reasonable and Customary (R&C) Pricing Guide
Medical Supplies – Claim Requirements
Dispensing Fee Update – June 2013
Dispensing Fee Update – June 2012
Some helpful industry terms:
Alternate Treatment (Dental)
- When there are two or more courses of eligible treatments, each of which would be adequate results for a given condition, a carrier will pay for the least expensive course of treatment, even if the more expensive treatment option is chosen by the claimant. Carriers work with professional dental consultants to determine the adequacy of various courses of treatments available.
- Is the percentage of eligible expenses payable by the carrier of a group plan. For example, if a benefit has a coinsurance of 80%, the carrier will pay the 80% of the expense (minus any deductible, if applicable) and the plan member pays the remainder.
- If a plan includes a deductible (ie $25 / year), this amount must be paid first before benefits become eligible for payment.
Dental Fee Guide:
- The dental association of each province publishes a dental fee guide each year. The guide summarizes recommended charges for each dental procedure. Guides are updated annually to account for inflation and other factors. Plan sponsors can choose which dental fee guide (current year, or specific year or specific province) to use to determine the maximum amount payable for each dental procedure in their plan.
- Generic drugs are a chemically equivalent alternative to brand-name drugs. They contain the same high quality active ingredients as brand-name drugs. They are federally tested using the same strict criteria for safety and effectiveness and must meet the same scientific norms and standards.
Generic drugs’ inactive ingredients, such as coatings, may differ (although the fillers used in drugs come from a limited range of available products) and they may appear different – in colour or shape – but they work the same. They are less expensive than brand-name drugs.
Dispensing Fee Cap:
- A plan sponsor can place a fixed dollar limit on dispensing fees (the fee charged by a pharmacy for filling a prescription).
Open Space Limitation:
- The Open Space limitation may apply to certain dental procedures that use appliances to replace extracted teeth. When a dentist recommends placing a prosthodontic appliance – such as a bridge or a denture – as part of the patient’s treatment plan, the carrier needs to know the extraction date for each tooth that the appliance will be replacing. If your plan includes this limitation, and any of the teeth involved were extracted before the patient became insured under the plan, the plan will not pay for the treatment. Check your benefit booklet to see if your plan includes the Open Space limitation.
Reasonable and Customary (R&C):
- A fee is reasonable and customary if its dollar value falls within the usual range of charges for the same or comparable services (or supplies) made by similar practitioners in an area.
Some helpful industry terms:
Adjusted Incurred Claims:
- The Incurred Claims, adjusted for Trend to be brought up to current levels.
- Paid Claims for an experience period, adjusted to include the Change in Reserve.
- The actual amount of claims submitted and paid within an experience period.
- Claims in excess of a pre-determined level that are removed from the Paid Claims in each experience period, so they will not impact the experience rating.
- Typically, all claims are removed for Emergency Out-of-Country, Accidental Dental and Private Duty Nursing services, as well as Drug claims in excess of the Drug Stop Loss amount per member and, in the province of Quebec, claims in excess of the limits set by RAMQ legislation.
- A factor reflecting the change in ratio of males to females, occupation and province of residence, as well as aging within a group. The renewal rates are partially based on the evolving composition of a group.
Economic Adjustment Factor:
- A factor used to adjust pricing at the benefit level in situations where the carrier makes changes to the manual rates and there is a lag updating all of the required tables. It can also be used as a transitional adjustment to help move pricing toward target levels.
- Represents the change required to bring current premium in line with the carrier’s manual rates.
- The expected increase to paid claims as the result of inflation, increased utilization, the introduction of new drugs and treatments, delisting of government services, deductible leveraging and changes to provincial dental fee guides.
- The Billed Premium for each experience period, adjusted to reflect current rates, demographic changes and the impact of plan amendments.
- The actual amount of premium billed to the client during each experience period.
- A representation of the amount of premium that would be required to be paid into Quebec’s provincially legislated RAMQ pool on behalf of the client for each experience period. This amount is deducted from the experience premium for each period.
- The probability that past claims experience for the client will be consistent and therefore an accurate reflection of claiming patterns that are likely occur in the future. Credibility to the client’s own experience will normally increase with the size of the group and the number of years of experience.
- The level of emphasis applied to each experience period used to calculate the Weighted Adjusted Incurred Loss Ratio, the weighting used depends on the benefit and the pattern of past experience.
Acceptable Loss Ratio (ALR):
- The ratio of claims to premium, reflecting the portion of premium required to cover claim costs. The balance covers required expenses for the plan.
Current Loss Ratio:
- The current loss ratio of claims to premium, reflecting the portion of premium required to cover claim costs.
Target Loss Ratio:
- The ratio of claims to premium, reflecting the portion of premium required to cover claim costs for the upcoming renewal period.
Adjusted Incurred Loss Ratio:
- The ratio of Adjusted Incurred Claims to Adjusted Premium. This ratio brings all premium and claims for an experience period up to current levels.
Experience Loss Ratio:
- The ration of Paid Claims to Billed Premium
Incurred Loss Ratio:
- The ratio of Incurred Claims to Billed Premium
Weighted Adjusted Incurred Loss Ratio:
- The blended result of the Adjusted Incurred Loss Ratio for each experience period based on the applied Weighting.
Adjusted Disabled Life Reserves:
- Reserve levels that reflect current morbidity and interest assumptions
Change in Reserve:
- The change in Disabled Life, IBNR and Waiver of Premium Reserves from the end of the previous experience period to the end of the current experience period.
Disabled Life Reserve:
- For each disabled plan member that has been approved for claim payment under the Long Term Disability benefit, the carrier assumes responsibility for payment until the claim terminates, regardless of whether or not the policy remains in force. In order for a carrier to meet this liability, they must establish a reserve for each disabled member based on a number of factors including age at the time of disability, gender and payment amount.
Incurred But Not Reported Reserve (IBNR):
- A reserve established to cover the liability for claims incurred by plan members during an experience period but, due to natural lag, will be reported to and paid by the carrier during the following period. The carrier retains liability for these lag claims, even if the client terminates their coverage.
- When notification is received that a Long Term Disability claim is in litigation, the carrier will set up a reserve to cover the potential liability.
Waiver of Premium Reserve:
- When a plan member has been approved for disability, payment of the Basic Life premium is waived. When a plan member becomes disabled, the carrier has responsibility for payment of the Life claim when it is incurred. To meet this liability, a reserve is established for each disabled member based on a number of factors including age at the time of disability, gender and volume of insurance.
INDUSTRY DRUG POOLING
- EP3 means a proprietary extended drug policy protection plan of a CDIPC member that meets CDIPC minimum EP3 standards.
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