PGSS HEALTH & DENTAL PLAN Carrier: Sun Life Plan name: PGSS Health & Dental Plan Policy no.: 56961 Identification no. : (McGill ID#) Plan holder: (Student's name) WHO CAN BE COVERED? PRICES FOR GRADUATE STUDENTS HEALTH DENTAL From September 2009 - August 2010 PGSS MEMBERS: Health Plan ............ $224.75 Graduate students Dental Plan ............ $189.75 Postdocs BOTH ........................ $414.50 International graduate students Spouses & children From January 2010 - August 2010* HOW DO I PAY FOR COVERAGE? Health Plan ............ $149.83 Dental Plan ............ $126.50 Registered by September 30, 2009 McGILL PGSS BOTH ........................ $276.33 Full-time status Additional session status PRICES FOR SPOUSE OR ONE CHILD Non-thesis extension status in addition to the students' price Postdocs From September 2009- August 2010 All other statuses Health Plan ............ $224.75 Spouses & children Dental Plan ............ $189.75 Registered after Sept. 30, 2009* BOTH ........................ $414.50 Registered for Winter term only* McGill will charge you automatically for these fees From January 2010 - August 2010* through your tuition and student fees account. Health Plan ............ $149.83 PGSS will manually enrol you through payment and Dental Plan ............ $126.50 submission of documents at the PGSS office. BOTH ........................ $276.33 * This can only occur during adjustment periods & must be requested to PGSS during the adjustment periods. PRICES FOR FAMILIES in addition to the students' price HOW DO I CONFIRM MY COVERAGE? spouse + unlimited number of children A software system charges fees based on McGill's From September 2009 - August 2010 fee codes. Please verify your charges and coverage Health Plan ............ $449.50 through Minerva, or by calling the PGSS office. Dental Plan ............ $379.50 BOTH ........................ $829.00 DETAILS OF THE PLAN & COVERAGE Available in the PGSS handbook, on the PGSS website, From January 2010 - August 2010* the ASEQ website (ihaveaplan.ca) and on various Health Plan ............ $299.66 pamphlets available at Thomson House Dental Plan ............ $253.00 BOTH ........................ $552.66 ADJUSTMENT PERIOD DEADLINES October 2, 2009 (fall term) * this category of coverage is available only February 5, 2010 (winter term) to graduate students registered for the first time in the Winter term or after Sept. 30, 2009. CONTACT US FOR ASSISTANCE ASEQ PGSS 1134 Ste-Catherine West David Thomson House Suite 700 3650 McTavish Montréal, Québec Montréal, Québec H3B 1H4 H3A 1Y2 Tel: (514) 789-8776 Tel: (514) 398-3756 Toll free: 1-866-795-4436 Fax: (514) 398-1862 ihaveaplan.ca email@example.com http://pgss.mcgill.ca Carrier: Sun Life Plan name: PGSS Health & Dental Plan Policy no.: 56961 Identification no. : (McGill ID#) Plan holder: (Student's name) This information is intended as a basic explanation of the benefits available to you through the PGSS Health & Dental Plan. The material summarizes the important features of your group plan and is prepared as information only and does not, in itself, constitute a contract. Benefits are subject to all conditions, limitations, exclusions and other terms of the master group insurance policy (available at ASEQ). Groups numbers: 56961-2A (members with Québec Medicare) or 56961-2B (all other members) Policy year: September 1, 2009 to August 31, 2010 Eligibility and payment Full-time & additional session Canadian Masters & Ph.D. students, and postdocs - Compulsory Health Plan and Dental Plan fees charged through your student account Full-time & additional session international graduate students - Compulsory Dental Plan fee charged through your student account Members residing outside of Canada - Not eligible - withdrawal required during the Adjustment Period Part-time Canadian graduate students - Optional enrolment payable at the PGSS Offfice during Adjustment Periods Part-time international graduate students - Optional enrolment in the Dental Plan, payable at the PGSS Office during Adjustment Periods Any students registered for their studies after September 30, 2009 - Optional enrolment payable at the PGSS Office during Adjustment Periods Spouse & Family Enrolments The Plan gives you the option of enrolling your family (spouse and/or dependants) by completing an Enrolment Form and paying an additional fee. Common law, civil union and same sex couples are eligible. Enrolment Forms are available at pgss.mcgill.ca/HEALTH. GLOSSARY Blackout Period: (for New Students Only): The first two months of the Fall term while ASEQ waits for complete enrolment lists. During this time, you may submit claims, but reimbursement will only be mailed once the Blackout Period ends. Practitioners and pharmacists do not accept Pay Direct or assignment of benefits during this period. Returning eligible students who were covered in the Winter 2009 semester will not experience a Blackout Period during the Fall semester. Similarly, only new Winter semester students will experience a Blackout Period in the Winter 2010 semester. Adjustment Period: The period at the beginning of each semester when you can either withdraw or enrol yourself, your spouse and/or dependants in the Plan (if eligible). Dependent children: Your children and your spouse’s children (other than foster children) are eligible dependants if they are not married or in any other formal union recognized by law, and are under age 22. A child who is a full time student attending an educational institution recognized under the Income Tax Act (Canada) is also considered an eligible dependant until the age of 26 as long as the child is entirely dependent on you for financial support. Québec resident: For the purposes of the PGSS Plan, a Québec resident is someone who holds a valid Québec Medicare card. Pay Direct Card: A card allowing non-Québec residents to fill prescriptions at most Canadian pharmacies without paying the full amount up front. The card is available online at ihaveaplan.ca and at the PGSS office. Spouse: The person who is your spouse by marriage or under any other formal union recognized by law, or your partner of the opposite sex or of the same sex who has been publicly represented as your spouse for at least the last year. Carrier: Sun Life Plan name: PGSS Health & Dental Plan Policy no.: 56961 Identification no. : (McGill ID#) Plan holder: (Student's name) PRESCRIPTION DRUGS The Plan covers most medications legally requiring a prescription, either the generic equivalent or the lowest actual cost. Most oral contraceptives, anti-smoking aids and insulin are covered under this benefit. Certain brand name drugs are covered only if your doctor indicates "no substitution" on the prescription. Benefits are not payable for over-the-counter drugs, fertility drugs, male pattern baldness remedies, vitamins (unless injected), vitamin and mineral preparations, food supplements, Viagra, or drugs not approved for sale in Canada. Please contact ASEQ for further information relating to prescription drugs. THE QUÉBEC PUBLIC PRESCRIPTION DRUG INSURANCE PLAN Under the Québec Public Prescription Drug Insurance Plan (RAMQ), all Québec residents must be covered under a private (not student) drug plan directly or as a dependant. Residents who do not have access to a spousal/parent or employee insurance plan must register with the RAMQ Drug Plan. All claims for prescription drugs must first be submitted to this other plan or to the RAMQ before being submitted to the PGSS Health Plan. Québec residents can be covered for up to 100% of eligible prescription drugs by combining their private/RAMQ and PGSS Health Plan. For registration and information, call the RAMQ at 1 888 435-7999. After submitting your eligible prescription drug costs to your private/RAMQ Drug Plan, you can use your PGSS Health Plan to cover the remaining costs, such as the co-payment or deductible from the other plan. Québec residents are not eligible to use the Pay Direct card. This card is only for non-Québec residents. IF YOU ARE A CANADIAN STUDENT COVERED BY QUÉBEC MEDICARE You should be covered under the Québec Public Prescription Drug Insurance Plan (RAMQ) (see above) 1. Present your Medicare card at the pharmacy upon purchase. 2. Tell the pharmacist that you are registered with the RAMQ Drug Plan. Your prescription will be processed with your provincial coverage taken into account. 3. Pay any deductible or co-payment required to the pharmacist. 4. Attach your receipts (originals only) to the Extended Health Claim Form. Make photocopies of all forms, receipts, and documents before sending by mail. 5. Mail to Sun Life, who will process the remaining reimbursements. IF YOU ARE A CANADIAN STUDENT WITH NON-QUÉBEC MEDICARE The PGSS Health Plan will cover your eligible prescription drug costs up to 90%, using the Pay Direct card. There is a yearly deductible for prescription drugs of $35 ($70 per family). You can download the Pay Direct card from ihaveaplan.ca or pick one up at the PGSS office. The card allows you to fill prescriptions at most Canadian pharmacies without paying the full amount up front. The pharmacist will be able to process the claim immediately, so you won't have to submit a hard-copy claim. Ensure that you present both your valid student ID and Pay Direct cards. Please note that the Pay Direct Card can't be accepted during the Blackout Period. IF YOU ARE AN INTERNATIONAL STUDENT COVERED BY QUÉBEC MEDICARE As an international student, your Québec Medicare coverage may not always be identical to the Medicare coverage of Québec residents. Please consult the special publication entitled "About RAMQ" to ensure you understand the coverage offered to you through Québec Medicare and how you are eligible to submit prescription drug claims to the RAMQ and/or the PGSS Health Plan. Carrier: Sun Life Plan name: PGSS Health & Dental Plan Policy no.: 56961 Identification no. : (McGill ID#) Plan holder: (Student's name) “ABOUT RAMQ” - QUEBEC’S MEDICARE PROVIDER These regulations apply to students and postdocs covered by the Quebec Medicare program. The RAMQ plan applies differently depending on your status and revenue. Consult RAMQ for details www.ramq.gouv.qc.ca or 1-888-435-7999. There are exceptions for international students and postdocs obtaining a Medicare card for the duration of their time at McGill. Find the document “About RAMQ” on the PGSS website for full details on these exceptions. QUEBEC LAW STATES THAT: Residents of Quebec must be covered for prescription drugs by an insurance plan. If these residents have access to an employee insurance plan (EIP), they are obligated to use it. If these residents do not have access to an employee insurance plan, they are obligated to use the RAMQ plan. EIP’s can be offered by your employer, your parents' employer or your spouse's employer. By virtue of being a "student plan", the PGSS plan does not qualify as an EIP. Therefore, you are obligated to use the RAMQ plan as your "primary" drug insurance and can use the PGSS plan as your "secondary" drug insurance. This means that you must claim your prescription drug costs to the RAMQ plan first (or EIP if available), and afterwards to the PGSS plan. HOW THE RAMQ UNIVERSAL DRUG PROGRAM WORKS: Eligibility: You must be under 65 years old without governmental employment assistance. Deductible: A monthly $14.30 fee must be paid by you upon purchasing prescription drugs. Coinsurance: After the initial $14.30, the remaining cost to be paid is 31% of the cost. The other 69% is paid by RAMQ. Maximum: Once you have paid out the monthly maximum, RAMQ pays for 100% of the remaining prescriptions during the month. The monthly maximum varies up to $77.21 depending on your yearly income. RAMQ premium: The amount of the annual premium varies from $0 to $570 per adult, depending on net family income. This amount is in effect from July 1, 2008 to June 30, 2009 and is subject to change. The premium is collected every year by the Ministère du Revenu du Québec when income tax returns are filled. PLEASE NOTE: 1. RAMQ will generally not reimburse prescription drug and pharmaceutical services obtained outside Quebec. 2. RAMQ cannot reimburse prescriptions drugs after three months have passed since the purchase date. YOUR RESIDENCY STATUS AT McGILL RAMQ considers you a "resident" if you have a Quebec Medicare card. However, McGill considers you a "resident" if you have provided the Registrar's Office with proof of residency in Quebec, allowing them to charge you Quebec tuition rates, rather than Canadian rates. Therefore, the classification provided to PGSS by McGill may not correspond to your classification with RAMQ. Please contact the PGSS office to make any corrections to your residency classification for the PGSS plan via 514-398-3756 or firstname.lastname@example.org. Carrier: Sun Life Plan name: PGSS Health & Dental Plan Policy no.: 56961 Identification no. : (McGill ID#) Plan holder: (Student's name) FEATURES OF THE PGSS HEALTH PLAN Vaccinations: Prescription and non-prescription vaccinations are covered 100%, up to a $50 maximum per policy year. Vision Care: The Plan covers the cost of new or replacement eyeglasses or contact lenses. The maximum allowed is $200 every 24 months. One eye exam is covered per policy year up to $30 maximum. Laser eye surgery is covered to a maximum of $150 per policy year. The Vision Network: ASEQ also offers a Vision Network, which is a comprehensive list of optometrists and opticians who provide vision care to students at a preferred rate. Consult ihaveaplan.ca for a list of participating clinics. Health Practitioners: The Plan covers the cost of physiotherapists, chiropractors, naturo- paths, osteopaths, dieticians (with a referral from a medical doctor), licensed psychologists, podiatrists/chiropodists, athletic therapists and speech therapists for a maximum of $20 per visit per category of practitioner for a total of $400 per policy year. All health practitioners must be registered with the appropriate licensing board in the province or country where the treatment is received. X-rays: One x-ray per policy year is included in the overall maximum for each of the following categories of practitioners: chiropractors, osteopaths, and podiatrist/ chiropodists. Chiropractic Care: Some Québec chiropractors offer preferred prices to students covered by the PGSS Health Plan. For a list of Network members in your region, visit ihaveaplan.ca. Medical Equipment & Services: The Plan covers the cost of stipulated medical equipment, including hearing aids, crutches, wheelchair rental, hospital-type bed and permanent prosthesis. Rigid and semi-rigid braces (not for athletic use), orthotics and orthopedic shoes are also covered. A home nurse is also covered when certified in writing as medically necessary by the attending physician and upon approval from Sun Life. Before incurring any medical equipment expense, you should contact ASEQ for the eligibility and any applicable maximums of all equipment. A medical doctor's authorization is required for all medical equipment claims. Diagnostic Services: Lab tests and ultrasounds used to diagnose an illness are covered only if your provincial health care doesn’t cover these services. They must be performed in a commercial lab. Ultrasounds for pregnancy and the monitoring of an illness are not covered by the PGSS Plan. Hospitalization: The Plan covers the cost of an upgrade from a public ward to a semi- private hospital room. A hospital cash benefit will provide $50 per day of hospitalization to offset any incidental expenses, payable from the first day and up to a 30-day maximum. Ambulance: The Plan covers the reasonable and customary charges for air or land ambulance service to the nearest hospital when an emergency requires immediate medical attention. The maximum is $250 per occurence. Tutorial Benefit: The Plan covers the cost of private tutorial services by a qualified teacher if an accident or illness causes disability and confinement to a home or hospital for seven (7) consecutive days. The benefit will be paid from the first day of confinement, up to a maximum of $10 per hour, to a maximum of $300 per accident or illness. This benefit is payable to the insured student only, and not to spouses or dependants. Carrier: Sun Life Plan name: PGSS Health & Dental Plan Policy no.: 56961 Identification no. : (McGill ID#) Plan holder: (Student's name) MORE FEATURES OF THE PGSS HEALTH PLAN Accidental Death & Dismemberment (AD&D) The Plan provides insurance for the loss of life or limb for paralysis caused by an accident. It provides payment of sums up to $37,500. For more details on AD&D benefits, eligibility and claim submission, contact ASEQ. Dental Accident The Plan covers the repair/replacement of natural teeth damaged through an accidental blow to the mouth according to the Provincial Dental Fee Guide for General Practitioners (the province where the service was performed). If you visit a specialist for covered services, your reimbursement will be processed according to the equivalent General Practitioner fee. Treatment must be completed within 12 months following the accident. The maximum paid is $2,500 per accident. Travel Health Coverage The Plan covers hospital, physician and other services for emergency treatment of an injury or illness while travelling outside of the province in which you are residing (including international travel). It covers reasonable and customary charges, which are in excess of the provincial Medicare allowance. You are covered for up to 120 days per trip, for an unlimited number of trips taken within the policy year. The maximum coverage is $5,000,000 per incident. You are also covered up to $1,500 for trip cancellation and up to $5,000 for trip interruption in case of a medical emergency for each trip taken during the policy year. Students who are away on a recognized academic exchange can have their travel health benefits extended during the first 120 days of the trip and for the duration of their exchange, plus another 120 days after their exchange, as long as they remain PGSS members, and keep their provincial health-care coverage. You must notify ASEQ before leaving on an exchange. The complete details of your benefits, coverage, and telephone numbers for emergency assistance can be found in your Travel Health Passport, available at ihaveaplan.ca. If you’re of planning to travel, you must bring this document with you. Health-care providers outside Canada may require this information prior to providing services. Please note that students and their dependants are not covered for out-of-province or out-of-country emergency services once they reach age 80. If you, or your spouse, are age 65 and older, a pre-existing condition clause applies to your medical conditions which existed in the 365 days prior to your departure from your province or territory of residence. For more details, contact ASEQ. Travel Health Claims Travel health coverage is provided by Mondial Assistance. If you use any of your travel benefits, you must call Mondial Assistance immediately to find out how and when to submit your claims. For more information visit ihaveaplan.ca and download the Travel Health Passport. Mondial Assistance Toll-free (Canada & US): 1 866-759-2882 Toll-free (International): 1 800 9220-9220 Collect calls: (519) 342-4948 Have your student ID number and contract number (no. 4709) on hand when you call. Carrier: Sun Life Plan name: PGSS Health & Dental Plan Policy no.: 56961 Identification no. : (McGill ID#) Plan holder: (Student's name) FEATURES OF THE PGSS DENTAL PLAN The benefits of your PGSS Dental Plan are part of a special program for students. Your dental benefits consist of two elements: 1. INSURED PORTION The insured portion of your PGSS Dental Plan covers a percentage of the recommended fee for covered services, according to the Provincial Dental Fee Guide for General Practitioners (according to the province where the service was performed), as indicated in the chart below. If you visit a specialist for covered services, your reimbursement will be processed according to the equivalent General Practitioner fee. 2. ASEQ DENTAL NETWORK The ASEQ Dental Network is an exclusive service provided to students enrolled in the PGSS Dental Plan. Network dentists, conveniently located in Montréal and other regions of Québec and Canada, offer a reduction of 20-30% off the Provincial Dental Fee Guide for General Practitioners' price of eligible dental services (refer to the chart below). You are covered for the insured portion regardless of the dentist you choose. An updated list of Network members is available at ihaveaplan.ca. INSURED PORTION (1) NETWORK COVERAGE TOTAL Preventive services 65% 30% 95% (recall exams (2), cleanings (2), extraction of impacted teeth (3)) Basic services 50% 20% 70% (fillings (4), oral surgery, endodontics, periodontics) Major restorative services 50% 20% 70% (crowns, bridges, posts) Notes: 1. Percentage of Provincial Dental Fee Guide for General Practitioners (province in which the service was performed). 2. Recall exams, cleaning/polishing, bitewing x-ray, oral hygiene instruction and the application of fluoride are covered once every 6 months. Scaling is covered up to four units per policy year. A complete exam (often called a new patient exam) is only covered once per 36 months. 3. The extraction of impacted teeth is part of preventive services. The ASEQ Dental Network reduction, however, will be 20% as this is considered oral surgery. 4. Fillings in amalgam (metal) are covered for all teeth. Composite (white) fillings are covered for the front teeth and pre-molars only. If you choose to have your back teeth filled in composite, your claim will be reimbursed according to the amalgam fee. * Services performed by an orthodontist are not covered by the Dental Plan. The maximum paid by Sun Life per policy year (Sept. 1, 2009 - Aug. 31, 2010) on the insured portion of the Dental Plan is $750. Certain exclusions and limits may apply. Before receiving dental treatment for work that is expected to cost $300 or more, you should submit a "predetermination form" obtained from your dentist for an estimate of reimbursements to be assessed by Sun Life. Carrier: Sun Life Plan name: PGSS Health & Dental Plan Policy no.: 56961 Identification no. : (McGill ID#) Plan holder: (Student's name) INSTRUCTIONS ON MAKING CLAIMS CLAIM FORMS AND RECEIPTS Claim forms are available at ihaveaplan.ca or pgss.mcgill.ca/HEALTH, and at ASEQ and PGSS . Photocopies of blank claim forms may be used . Only original receipts are accepted. OUT-OF-COUNTRY EXPENSES You can use your health and dental benefits anywhere in the world. Reimbursements are made in Canadian funds and calculated at the exchange rate of the day the claim is processed. Reimbursement is limited to what the service would have cost if done in Canada. When applicable, claims will be coordinated with your provincial Medicare coverage. Ensure that you submit detailed receipts for services performed while outside of Canada. PRESCRIPTION DRUGS Refer to the section on prescription drugs to find instructions on purchasing and making prescription drug claims. Your provincial status will determine how you can buy and obtain reimbursements for these expenses. VISION AND ALL OTHER HEALTH CLAIMS Québec residents who are claiming balances for prescription drugs should also follow these steps. 1. Complete and sign the health claim form (include your student ID # and group number); 2. Attach the original receipts and all other required documents (eg. doctor's referrals) 3. Make photocopies of all forms, receipts and documents before sending by mail. 4. Mail to the insurance company at the address indicated on the back of the claim form. 5. If using the Network: Present your student ID card to have the insured portion of the expense paid on a pay-direct basis. Complete and sign the claim form with the optometrist. S/he will be responsible for processing the remainder of the expense with the insurance company. Please note that Greiche & Scaff and LASIK MD do not offer the Pay-Direct system. ACCIDENTAL DEATH & DISMEMBERMENT / TRAVEL HEALTH COVERAGE CLAIMS Contact ASEQ for instructions on how to submit these expenses for reimbursements. DENTAL CLAIMS 1. You and your dentist must complete the dental claim form together. 2. Forms can be submitted by mail or electronically by the dentist's office. 3. If you are using the dentist's generic claim form, ensure that you indicate the Plan's group policy number and use your student ID for the 'certificate' or 'identification' number 4. You can assign benefits to your dentist by signing the box on the dental claim form giving authorization to assign benefits to the dentist. Reimbursement will be sent directly to the dentist. You will only have to pay the portion not covered by the insurance and/or Dental Network reduction. Consult your dentist to find out if s/he accepts this method. COORDINATING BENEFITS Those with simultaneous coverage with other plans should contact ASEQ for instructions. DEADLINES Health and Dental claims must be received by Sun Life no later than 90 days after the end of the policy year in which claims were incurred or 90 days after the end of your coverage, whichever is sooner. Accidental death and dismemberment claims must be submitted immediately. Prescription drugs claims should be submitted immediately after purchase. Carrier: Sun Life Plan name: PGSS Health & Dental Plan Policy no.: 56961 Identification no. : (McGill ID#) Plan holder: (Student's name) OTHER IMPORTANT INFORMATION ADVANTAGES OF A HEALTH AND DENTAL PLAN A growing number of important health-care services are not covered by provincial Medicare. For many students and postdocs, paying for these services can lead to financial hardship, while others cannot afford them at all. To help pay for these health services, this plan was put in place by PGSS. The Plan is uniquely designed for you, providing a comprehensive package of health, dental, vision and travel benefits to fill the gaps left by provincial Medicare, and other private plans. ADVANTAGES OF A GROUP PLAN Each year, in March, the PGSS holds a referendum to obtain the mandate from its members to continue offering a compulsory insurance plan. The PGSS has offered such a plan to McGill graduate students since 1995. The compulsory nature of the Plan is based on the concept of 'group insurance' which offers better coverage at a better price for a larger group rather than for individual users. Dental costs, unforeseen accidents or illnesses, travel insurance costs, chronic illnesses, sports injuries and birth control can be financial burdens for those who do not have access to another insurance plan (coverage on parental plans generally ends at the age of 25 and employer plans are not always available to full-time students). The PGSS Plan provides its members with the security that if health expenses should arise, they will often obtain some reimbursement for these costs. ADVANTAGES OF A COMPULSORY PLAN Members contribute to the Plan by payment of the yearly price. The more members in the group, the lower the price of the yearly cost. DETAILS OF A COMPLEMENTARY / SUPPLEMENTAL PLAN The Plan functions as supplemental insurance which means it covers those costs that are not covered by provincial Medicare. Whereas Medicare will cover the costs of visiting an emergency room, it will not cover the cost of an ambulance. Nor will it cover the costs of physiotherapy, contact lenses, or travel insurance. Supplemental insurance kicks in to help you bear these outstanding costs. GROUP INSURANCE AND THE QUEBEC DRUG PLAN Residents of Quebec, and those covered by Quebec Medicare, need to be aware of the restrictions of group insurance relating to the prescription drug insurance with PGSS. Please refer to the information “About RAMQ" on the next page. ENROLMENT AND WITHDRAWAL Eligibility for enrolment and withdrawal are outlined on p. 1 of this booklet. Please refer to these details prior to making decisions on your coverage for you and your family. ADJUSTMENT PERIOD DEADLINES Enrolments and withdrawals occur during the adjustment periods; Students/Postdocs registered prior to September 30, 2009: Aug 1 to Oct 2, 2009 Students/Postdocs registered after September 30, 2009: Jan 4 to Feb 5, 2010 PGSS members with exceptional circumstances should contact the PGSS Office without delay.