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渥太华大学的“补充医保计划”
[ 编辑:admin | 时间:2014-09-27 09:52:10 | 浏览:3415次 | 来源:isbbs | 作者:加拿大小蝌蚪 ]

http://gsaed.ca/wp-content/uploads/2013/09/GSAEDbooklet.pdf

DESCRIPTION OF BENEF
ITS
HEALTH BENEFIT PLAN
Your plan is intended
to supplement your provincial health insurance plan. The benefits shown below
will be eligible, if they are reasonable and customary, and are medically necessary for the treatment of
an illness or injury.
Benefits are subject to the Deductible and Maxim
ums listed.
DEDUCTIBLE:
Nil
OVERALL MAXIMUM:
$5,000 per benefit year, for all health
expenses
Benefit Year: September 1
-
August 31
Prescription Drugs Benefit
(Prescription Drugs Benefit
does not apply if you have opted out of this
coverage.
)
PRESCRIPTION DRUGS
Your Co
-
pay:
Maximum plan pays:
x
Oral Contraceptives
x
Other Contraceptives
(Nuvaring, Mirena IUD,
Patches and all Injections)
x
All
other
covered drugs
50% per prescription or
refill for vaccines
20% per prescription or
refill
for all other drugs
$285 per benefit year
(combined with Other
Contraceptives)
$2,000 per benefit year
Prescription drug benefits must:
a)
be prescribed by a legally qualified medical practitioner or dental practitioner as permitted by law;
b)
legally require a prescription
;
c)
be submitted to us by using your Green Shield ID Card at your pharmacy or paid for by you and
then submitted to us for reimbursement.
If approved by Green Shield, this plan includes drugs that do not legally require a prescription, including
insulin and all other approved injectibles, as well as related supplies such as diabetic syringes, needles
and testing agents.
Certain drugs may re
quire prior approval, your Pharmacist is aware of the drugs that fall into this
category.
In no event will the amount dispensed exceed a three
-
month supply (six months if a vacation supply is
required)
of a prescription at any one time
and not more than a
13
-
month supply in any 12 consecutive
months.
Eligible benefits do not include and no amount will be paid for:
a)
Smoking cessation products, and medication for the treatment of hair loss/replacement, obesity,
erectile dysfunction and infertility.
b)
Products
which may lawfully be sold or offered for sale other than through retail pharmacies, and
which are not normally considered by practitioners as medicines for which a prescription is
necessary or required.
c)
Ingredients or products which have not been approved
by Health Canada for the treatment of a
medical condition or disease and are deemed to be experimental in nature and/or may be in the
testing stage.
DESCRIPTION OF BENEFITS
HEALTH BENEFIT PLAN
2
d)
Mixtures, compounded by a pharmacist, that do not conform to Green Shield’s current Compound
Policy.
Extended Health Services
All Health Benefits are subject to the Deductible.
HOSPITAL ACCOMMODATION
Your Co
-
pay:
Maximum plan pays:
Public general hospital or convalescent or
rehabilitation hospital
or public chronic
hospital
-
semi
-
private room
50%
5
days
per disability
Reimbursement of reasonable and customary charges
,
in the area where received, for accommodation
in a public general hospital, or a convalescent or rehabilitation hospital or a convalescent or rehabilitation
wing in a public general
hospital, or a public chronic hospital or chronic care in a public general hospital,
provided your provincial health insurance plan has accepted or agreed to pay the ward or standard rate.
No amount will be paid
for accommodation in a Long Term Care facility.
MEDICAL ITEMS AND SERVICES
Your Co
-
pay:
Maximum plan pays:
Braces
Compression Stockings
Other items and services listed below
50%
50%
0%
$500 per benefit year
$500 per benefit year
Reasonable and
customary charges
Reimbursement for reasonable and customary charges for:
a)
Aids for daily living: such as hospital style beds, including rails and mattress
es
; bedpan
s
; urinal
s
;
standard commode
s
; decubitus supplies; IV stand
s
; trapeze
s
; portable patient
lift
s
;
b)
Braces, casts;
c)
Incontinence/Ostomy
equipment
, such as catheter supplies and ostomy supplies;
d)
Mobility aids, such as cane
s
, crutch
es
, walker
s
and wheelchair
s
;
e)
Prosthetics, such as
an
arm, hand, leg, foot, breast, eye and larynx;
f)
Respiratory/Cardiolog
y
equipment
, such as compressor
s
, inhalant devices, tracheotomy supplies
and oxygen;
g)
Compression stockings.
Some items may require pre
-
authorization. To confirm eligibility prior to purchasing or
renting equipment, submit a Pre
-
Authorization Form to Gree
n Shield.
Limitations
a)
The rental price of durable medical equipment will not exceed the purchase price. Green Shield’s
decision to purchase or rent will be based
on the physician’s estimate of the duration of need as
established by the original prescription. Rental authorization may be granted for the prescribed
duration. Equipment that has been refurbished by the supplier for resale is not an eligible benefit.
DESCRIPTION OF BENEFITS
HEALTH BENEFIT PLAN
3
b)
Durable medical equipment must be appropriate for use in the home, able to withstand repeated
use and generally not useful in the absence of illness or injury.
c)
When deluxe medical equipment is a covered benefit, reimbursement will be made only when
deluxe
features are required in order for the patient to effectively operate the equipment. Items
that are not primarily medical in nature or that are for comfort and convenience are not eligible.
EMERGENCY TRANSPORTATION
Your Co
-
pay:
Maximum plan pays:
0%
$250 per benefit year
Reimbursement for professional land or air ambulance to the nearest hospital equipped to provide the
required treatment, or when medically required as the result of an injury, illness or acute physical
disability.
PRIVATE DUTY
NURSING IN THE HOME
Your Co
-
pay:
Maximum plan pays:
0%
Reasonable and customary charges. Minimum
8 hours per shift
Reimbursement for the services of a Registered Nurse (R.N.) or Registered Practical Nurse/Licensed
Practical Nurse (R.P.N./L.P.N.) in
the home on a full or part shift basis, up to the amounts shown above.
No amount will be paid for services which are custodial and/or services which do not require the skill
level of a Registered Nurse (R.N.) or Registered Practical Nurse/Licensed Practi
cal Nurse
(R.P.N./L.P.N.).
A Pre
-
Authorization Form for Private Duty Nursing must be completed by the attending physician and
submitted to Green Shield.
PROFESSIONAL SERVICES
Your Co
-
pay:
Overall Maximum
:
$400 per covered person,
per benefit year, for
all types of practitioners
combined
x
Chiropractor
0%
$
20
per visit, limited to the Overall Maximum
x
Registered Massage Therapist (medical
referral required)
0%
$
20
per visit, limited to the Overall Maximum
x
Naturopath, Physiotherapist, Speech
Therapist
0%
$20 per visit, limited to the Overall Maximum
x
Psychologist
0%
$35 per visit, limited to the Overall Maximum
Professional Services,
and for practitioners included,
up to the amount shown above, when the
practitioner rendering the service is
licensed by their provincial regulatory and/or professional association
and that association is recognized by Green Shield. Please contact the Green Shield Customer Service
Centre to confirm practitioner eligibility.
DESCRIPTION OF BENEFITS
HEALTH BENEFIT PLAN
4
ACCIDENTAL DENTAL
Your Co
-
pay:
Maximum plan pays:
0%
Reasonable and customary charges
Reimbursement for the services of a licensed dental practitioner for dental care to restore the area
damaged as the result of an accident while the coverage is in force. When natural teeth have
been
damaged, eligible services are limited to one set of artificial teeth. You must notify Green Shield
immediately following the accident and the treatment must commence within 180 days of the accident.
Green Shield will not be liable for any services
performed after the earlier of a) 365 days following the
accident, or b) the date you or your dependent cease to be covered under this plan.
No amount will be paid for periodontia or orthodontia treatments or the repair or replacement of artificial
teeth.
Charges will be based on the current Provincial Dental Association Fee Guide for General Practitioners
in the province of residence. Approval will be based on the current status and/or benefit level of the
covered person at the time that we are notified
of the accident. Any change in coverage will alter Green
Shield’s liability.
In the event of a dental accident, claims should be submitted under the health benefit plan before
submitting them under the dental plan.
VISION
Your Co
-
pay:
Maximum plan
pays:
x
Prescription eye glasses or contact
lenses, or medically necessary contact
lenses
x
Optometric eye exams
0%
0%
$100 per 24 consecutive months based on first
paid claim
Once every 24 months, up to a maximum of
$50
Reimbursement for the following services performed by a licensed Optometrist, Optician or
Ophthalmologist, up to the amounts shown above for:
a)
Prescription eyeglasses or contact lenses;
b)
Medically necessary contact lenses when visual acuity cannot otherwise
be corrected to at least
20/40 in the better eye or when medically necessary due to keratoconus, irregular astigmatism,
irregular corneal curvature or physical deformity resulting in an inability to wear normal frames;
c)
Replacement parts to prescription eye
glasses;
d)
Plano sunglasses prescribed by a legally qualified medical practitioner for the treatment of
specific op
hthalmic diseases or conditions;
e)
Optometric eye examinations for visual acuity performed by a licensed optometrist,
ophthalmologist or physician, (available only in those provinces where eye examinations are not
covered by the
provincial health insurance plan
).
Eligible benefits do not i
nclude and no amount will be paid for:
a)
Medical or surgical treatment;
b)
Special or unusual procedures such as, but not limited to, orthoptics, subnor
mal vision aids and
aniseikonic lenses;
c)
Follow
-
up visits associated with the dispensing and fitting of contac
t lenses;
d)
Charges for eyeglass cases.
DESCRIPTION OF BENEFITS
HEALTH BENEFIT PLAN
5
TUTORIAL BENEFIT
Your Co
-
pay:
Maximum plan pays:
NOTE: Your dependents are not eligible
for this benefit.
0%
Private tutorial service of a qualified teacher up
to $15 per hour, up to $1,000 per disability.
You must be confined to home or hospital for a
minimum of 30 consecutive days to qualify.
Health Benefit Exclusions
Eligible benefits do not include and reimbursement will not be made for:
1.
Services or supplies received as a result of disease, illness
or injury due to:
a)
intentionally self
-
inflicted injury while sane or insane;
b)
an act of war, declared or undeclared;
c)
participation in a riot or civil commotion; or
d)
committing a criminal offence;
2.
Services or supplies provided while serving in the
armed forces of any country;
3.
Failure to keep a scheduled appointment with a legally qualified medical or dental practitioner;
4.
The completion of any claim forms and/or insurance reports;
5.
Any specific treatment or drug which:
a)
does not meet accepted standards of medical, dental or ophthalmic practice, including charges
for services or supplies which are experimental in nature,
or is not considered to be effective
(either medically or from a cost perspective, based on Health Cana
da’s approved indication for
use);
b)
is an adjunctive drug prescribed in connection with any treatment or drug that is not an eligible
service;
c)
will be administered in a hospital;
d)
is not dispensed by the pharmacist in accordance with the payment method shown
under the
Prescription Drugs Benefit;
e)
is not being used and/or administered in accordance with Health Canada’s approved indication
for use,
even though such drug or procedure may customarily be used in the treatment of other
illnesses or injuries.
6.
Servic
es or supplies that:
a)
are not recommended, provided by or approved by the attending legally qualified (in the opinion
of Green Shield) medical practitioner or dental practitioner as permitted by law;
b)
are legally prohibited by the government from coverage;
c)
y
ou are not obligated to pay for or for which no charge would be made in the absence of benefit
coverage or for which payment is made on your behalf by a not
-
for
-
profit prepayment association,
insurance carrier, third party administrator, like agency or a p
arty other than Green Shield, your
plan sponsor or you;
d)
are provided by a health practitioner whose license by the relevant
provincial regulatory and/or
professional association
has been suspended or revoked;
e)
are not provided by a designated provider of se
rvice in response to a prescription issued by a
legally qualified health practitioner;
f)
are used solely for recreational or sporting activities and which are not medically necessary for
regular activities;
DESCRIPTION OF BENEFITS
HEALTH BENEFIT PLAN
6
g)
are primarily for cosmetic or aesthetic purposes,
or are to correct congenital malformations;
h)
re
provided by an immediate family member related to you by birth, adoption, or by marriage
and/or a practitioner who normally resides in your home. An immediate family member includes a
parent, spouse, child or sibling;
i)
are provided by your plan sponsor and
/or a practitioner employed by your plan sponsor, other
than as part of an employee assistance plan;
j)
are a replacement of lost, missing or stolen items, or items that are damaged due to negligence.
Replacements are eligible when required due to natural wea
r, growth or relevant change in your
medical condition but only when the equipment/prostheses cannot be adjusted or repaired at a
lesser cost and the item is still medically required;
k)
are video instructional kits, informational manuals or pamphlets;
l)
are fo
r medical or surgical audio and visual treatment;
m)
are special or unusual procedures such as, but not limited to, orthoptics, vision training,
subnormal vision aids and aniseikonic lenses;
n)
are delivery and transportation charges;
o)
are for Insulin pumps and s
upplies (unless otherwise covered under the plan);
p)
are for medical examinations, audiometric examinations or hearing aid eva luation tests;
q)
are batteries, unless specifically included as an eligible benefit;
r)
are a duplicate prosthetic device or appliance;
s)
a
re from any governmental agency which are obtained without cost by compliance with laws or
regulations enacted by a federal, provincial, municipal or other governmental body;
t)
would normally be paid through any provincial health insurance plan,
Workplace Sa
fety and
Insurance Board or tribunal
, the Assistive Devices Program or any other government agency, or
which would have been payable under such a plan had proper application for coverage been
made, or had proper and timely claims submission been made;
u)
were previously provided or paid for by any governmental body or agency, but which have been
modified, suspended or discontinued as
a
result of changes in provincial health plan legislation or
de
-
listing of any provincial health plan services or supplies;
v)
may include but are not limited to, drugs, laboratory services, diagnostic testing or any other
service which is provided by and/or administered in any public or private health care clinic or like
facility, medical practitioner’s office or residence, where
the treatment or drug does not meet the
accepted standards or is not considered to be effective (either medically or from a cost
perspective, based on Health Canada’s approved indication for use);
w)
are provided by a medical practitioner who has opted out o
f any provincial health insurance plan
and the provincial health insurance plan would have otherwise paid for such eligible service;
x)
relate to treatment of injuries arising out of a motor vehicle accident
(Ontario)
;
Note: Payment of benefits for claims re
lating to automobile accidents for which coverage is
available under a motor vehicle liability policy providing no
-
fault benefits will be considered only
if

i) the service or supplies being claimed is not eligible; or
ii) the financial commitment is comp
lete.
A letter from your automobile insurance carrier will be required;
y)
are cognitive or administrative services or other fees charged by a provider of service for services
other than those directly relating to the delivery of the service or supply.


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