August 16, 2024
Yes. The Appeal Process is designed to allow a member to seek further clarification when their benefit claim has been partially or totally declined and they are unclear about or disagree with the reason for the claim denial. In the initial claim adjudication and at every step of the Appeal process the claim is reviewed and a decision to approve or decline coverage is reached based on whether it is an eligible expense according to the provisions (i.e.plan design) of the benefit contract. You can view the step-by-step appeal process (150kB PDF) here.
There is no process for a member to request coverage on an exception basis for an expense that is not eligible for coverage according to provisions of the benefit contracts. The benefit contract outlines the types of drugs, services and supplies that are eligible for coverage and available to all eligible members of the benefit plan. It ensures that all members are treated in a fair, consistent and equitable fashion. To provide coverage for a drug, service or supply which is not listed as an eligible expense in the contract for one member could subject the OSSTF ELHT Board to accusations of discrimination when another request is declined. The OSSTF ELHT board is responsible for operating the OSSTF Benefits Plan and ensuring its financial sustainability. Adhering to the benefit plan contract provisions also allows the OSSTF ELHT Board to determine the cost of running the benefit plan and therefore its future sustainability.
The only way to provide coverage for new drugs, services or supplies not currently eligible for coverage would be to amend the benefit plan designs such that all eligible members of the benefit plans would have access to the new type of coverage.
The OSSTF ELHT Board has a Funding and Plan Design Modelling and Compliance Committee which meets approximately 3-4 times a year to look at current plan costs, funding and to review plan design. The OSSTF Benefits Advisory Workgroup also meets at least twice a year and serves to provide input to the Committee in this regard. All members will be informed when any plan design changes are implemented by the OSSTF ELHT.
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