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Your group benefits plan is provided to you by the OSSTF Employee Life and Health Trust (ELHT) Benefits plan and was established to help cover or supplement the cost of delivering health and dental benefits to you and your family. 

The OSSTF Benefits plan is responsible for ensuring that your benefits plan is managed sustainably and efficiently. The level of coverage your plan provides is directly related to the funding received by the OSSTF Benefits plan. 

Benefits fraud and abuse can put the OSSTF Benefits plan at risk and has negative consequences for the sustainability of your benefits plan. 

Benefits fraud and abuse can lead to higher costs, reduced coverage, or both. While some consider benefits fraud a victimless crime, it impacts every member of the OSSTF Benefits plan. It also directly impacts the ability of your OSSTF Benefits plan to provide optimum coverage amounts and maintain overall plan sustainability.

Benefits fraud vs. abuse

Fraud is the intentional submission of false or misleading information for the purpose of financial gain. Fraud is a crime, and those who are convicted may face serious consequences, including potential job loss, criminal conviction, jail time and fines. Some common examples of provider/plan member fraud include:

• Falsifying procedures to receive payment for health and/or dental expenses that are not eligible.
• Providing invoices that have been changed.
• Billing for health and/or dental services that haven’t been provided.
• Returning items after reimbursement.
• Submitting claims for forged or stolen prescriptions.
• Submitting claims from health-care or dental clinics that don’t exist.

Abuse is when a health or dental provider or an OSSTF Benefits plan member take advantage of your OSSTF Benefits plan provisions for personal gain. This includes overuse of services, excessive billing and accessing or providing treatment when there is no proven medical need. These types of benefit abuses have a negative impact on your OSSTF Benefits plan. Some common examples of provider/plan member abuse include:

• Providing/accessing medically unnecessary treatments and/or treatments for longer than necessary.
• Offering/accepting incentives such as free gifts (e.g. “free” shoes) to encourage maximum use of benefits.
• Referring patients unnecessarily to other providers in a practice or clinic.
• Encouraging all family members to access treatment not medically required.
• Using benefits up to the specific maximums where applicable, even if the products and services are not medically necessary or the products will not be utilized.
• Visiting multiple doctors and/or pharmacies to get narcotics.

You can help protect your OSSTF Benefits plan. Here’s how. 

Fraud and abuse can be committed by service providers, plan members, or both parties. Sometimes benefits fraud and/or abuse can happen without the plan members consent or knowledge. As an OSSTF Benefits plan member you can help to protect your plan, and yourself, from benefits fraud and abuse. 

Do:

• • Use your OSSTF Benefits plan for its intended purpose – coverage for eligible expenses incurred for the medically-necessary treatment of illness or injury.
  • Make sure your health or dental provider is licensed with the appropriate regulatory board and has not been delisted by the claims payor, Manulife. To find out which service providers have been delisted and avoid delays in processing your claims, check out how can I view the list of delisted providers.
  • Make sure that you are not being charged for extra services/equipment, and that you understand the services you are receiving, and your receipts accurately reflect those services.
  • Notify and reimburse the claims payor, Manulife, if you return previously claimed items for a refund.
• Report odd or suspicious behaviour or practices to OTIP Benefits Services at 1-866-783-6847. We also encourage you to review your claim statement or Explanation of Benefits (EOB) for accuracy and report any concerns or billing discrepancies. 

Do not:

• Be enticed to use your plan through the offer of cash rebates, “free” shoes or other products.
• Sign blank health and/or dental claim forms. Be sure to report dental and health-service providers who ask you to sign them.
• Submit a claim prior to receiving the dental or medical treatment, product, or service.
• Accept receipts for services or supplies you have not received.
• Share your plan and ID numbers with anyone other than your eligible dependants or service providers you have authorized to submit electronic claims on your behalf.
• Share or give anyone (including your dependants) your password to your OTIP member site, as you are responsible for your plan activity. 

Every dollar paid out due to a fraudulent claim is one more dollar that is not available for legitimate dental or healthcare needs. Any claim suspected to be fraudulent is thoroughly investigated by Manulife, and claims proven to be fraudulent are reported to OSSTF Benefits for review and action in accordance with the OSSTF Benefits fraud policy.  Review your anti-fraud policy.

If you suspect that someone you know or a service provider may be committing fraud, you can report it to OSSTF Benefits, OTIP, or Manulife. It is our shared responsibility to protect the plan and report fraud when we see it.
 
Questions? Check your benefits booklet for benefit plan terms and coverage details. You can also contact OTIP Benefits Services at 1-866-783-6847.

Related articles: 

Don’t let others put your benefits at risk

Learn how to spot benefits fraud – and protect your plan

OSSTF Benefits Fraud Newsletter

For active members, Basic Life and Accidental Death and Dismemberment (AD&D) benefit premiums are paid for from negotiated funding from the Government and, therefore, are considered a taxable benefit and a T4A slip is issued. As the plan administrator of your OSSTF Benefits Plan, OTIP is working on issuing the T4As for the 2018 tax year (January 2018 to December 2018 ) and as previously communicated, has obtained Social Insurance Numbers from employers to issue these T4As.

We are pleased to advise that members can now elect to have their T4As posted securely online through the OTIP member site. OTIP is sending the communication below to allow members to choose this option if they want it. As indicated in this communication, if members wish to access their T4A slip online, they must complete the steps outlined by February 14, 2019 and the T4As will be posted and available on or after February 28, 2019.

For active members who do not choose this option or for members who are not active, T4As will be sent via Canada Post to the address that OTIP has on file.

To learn more about the T4A slip, members can visit the Help Centre (scroll down to Browse Questions by Product Category and select T4A Slip) on OTIP’s website under frequently asked questions, or they can contact OTIP Benefits Services at 1-866-783-6847.

Go green!

Access your OSSTF Benefits ELHT T4A slip securely online

To help you with your 2018 tax return, you can now access your OSSTF Benefits Employee Life and Health Trust (ELHT) T4A slip online, through OTIP’s secure member site.

Why am I receiving a T4A slip from the OSSTF Benefits ELHT?

If your Basic Life and Accidental Death and Dismemberment (AD&D) benefit premiums are paid for by your ELHT, they are considered a taxable benefit and a T4A slip is issued. As the plan administrator of your OSSTF Benefits Plan, OTIP will issue your T4A slip.

The benefit amounts shown on your T4A slip are calculated based on the Basic Life and AD&D benefit premiums paid for you by the OSSTF Benefits ELHT, for the 2018 tax year (January to December).

Get your T4A slip securely online through OTIP’s secure member site.

Accessing your T4A slip online is quick, convenient and secure. You can print and re-print your T4A slip at any time!

What you need to do*:

*If you completed these steps prior to receiving this email, thank you! No additional action is required.

1. Go to www.otip.com and click on the Log in button.
2. Select Health and Dental from the drop-down menu and log in.
3. After you have logged in, a new screen will appear giving you the option to access your T4A slip electronically. Choose ‘Yes, I’d like to access my T4A slip online’.

If you wish to access your T4A slip online, you must complete these steps by February 14, 2019. Then, check back on or after February 28, 2019 to access your T4A slip on the secure member site.

If you do not wish to access your T4A slip electronically, no action is required by you and OTIP will mail your T4A slip via Canada Post to the address we have received from your school board.

To learn more about your T4A slip, you can visit the Help Centre (scroll down to Browse Questions by Product Category and select T4A Slip) on OTIP’s website for frequently asked questions, or you can contact OTIP Benefits Services at 1-866-783-6847.

Boards and School Authorities have been provided with a OSSTF New Hire Letter (226kB PDF) and the OSSTF Benefits at a glance (168kB PDF) that they are encouraged to pass on to new hires. New members are encouraged to access these documents for their enrolment questions, or to call OTIP Benefits Services at 1-877-783-6847 if they do not receive their enrolment invite or if they need assistance in the enrolment process.

In families with two working adults, it is common to have access to more than one health plan. There may be some overlap in the types of benefits and/or services they cover.

Co-ordination of benefits is how insurance companies co-ordinate benefits and claim payments when you have coverage under more than one group health plan. This procedure, set out by the Canadian Life and Health Insurance Association (CLHIA), establishes which plan pays first and how benefits are calculated when a person makes a claim to more than one group plan, either as a member or as a dependant (spouse or child).

How does co-ordination of benefits help you and your plan?

By co-ordinating your plans together:

• You can get up to 100% of your money back on your health and dental costs.
• Your plan can share the expense with the other insurance plan which will have a positive impact on the long-term sustainability of the OSSTF Benefits Plan.

Ready to co-ordinate your benefits plans?

For more information on co-ordination of benefits, you can check out:

• How it works (Part 1)
• Setting it up in My Benefits (Part 2) and My Claims (Part 3)

You can now check to see what specific brands and models of orthopaedic shoes may be covered by your OSSTF Benefits Plan. To see this list, log in to My Claims.

Before you purchase orthopaedic shoes:

• Review your benefits booklet for plan details (check under Non-Dental Prostheses, Supports and Hearing Aids) and find out if you qualify.
• Check the list to find out if your shoes are covered or not.
• Submit an estimate to OTIP to see if your shoes will be paid for and that you have all the supporting documents.
• Learn more about what is needed to submit an estimate or a claim for orthopaedic shoes.

Important notes:

• Recommendation of either a physician or a podiatrist is required for stock-item orthopaedic shoes and modifications/adjustments to stock-item orthopaedic shoes.
• All other coverage and eligibility requirements apply.
• The list is subject to change without notice.

The list is available in English only.

As we approach the end of the year, please be mindful of some service providers’ marketing campaign to ‘use it or lose it’. These campaigns are designed to serve the providers who promote them, however using benefits that are not medically necessary does not serve to protect the overall health of your plan.

Benefits like massage therapy and orthotics have balances that reset every benefit year to ensure proper care as necessary for plan members and their families. However, if it is not medically necessary, maximizing all of your benefits will negatively impact the long-term sustainability of the benefits plan, and may affect everyone’s ability to access necessary benefits in the future. Therefore, your responsible use of the plan is in the best interests of yourself, your family and fellow plan members.

Your benefits plan is designed to provide you and your family with financial protection for a variety of medical expenses, including prescription drugs. The Prior Authorization Program helps to manage drug costs while continuing to provide you with access to appropriate drug therapy. The program validates that the drug is prescribed for its intended use and meets the terms and conditions outlined in your benefits booklet.

For a specific list of drugs, additional medical information is needed before determining if the drug is eligible. A drug may be prescribed to treat different medical conditions; one condition that may be covered under your benefits plan and one that may not be.

NOTE: The list of drugs requiring prior authorization is updated regularly, so be sure to check it each time you receive a new prescription.

Here are some helpful hints to keep in mind the next time you visit your doctor or pharmacist or prescribed a drug:

Use My drug plan to look for generic drug options

My drug plan is a user-friendly, drug lookup tool (found in My Claims quick links). It can help you to manage your drug costs especially because you have a mandatory generic drug plan. You can find out if a generic drug is available or if prior authorization is needed. A drug library is also right at your fingertips

IMPORTANT NOTES:

• Drug costs seen in My drug plan are estimates only.
• With a mandatory generic drug plan, any prescribed drug cost cannot exceed the price of the lower cost alternative drug, which is typically a “generic” drug.
  • If the drug you are prescribed is a “brand-name drug,” and there is no generic or interchangeable drug, your plan will reimburse you the cost of the brand name drug.
  • If there is a generic drug and you choose to buy the brand-name drug, your plan will reimburse you the cost of the generic drug.
  • In some instances, you may experience an adverse reaction to the generic drug, or it is therapeutically ineffective. When this happens, medical evidence can be submitted to support why the brand-name drug is being prescribed. To get approved for a brandname drug, you need to complete the Request for Approval of Brand-Name Drug form, have it signed by your doctor and return it to the address on the form. If approved, you will be paid back the cost of the brand-name drug.

To help manage the costs associated with prescription drugs, the OSSTF Benefits Plan includes mandatory generic substitution.

With a mandatory generic drug plan, any prescribed drug cost cannot exceed the price of the lower cost alternative drug, which is typically a “generic” drug.

• If the drug you are prescribed is a “brand-name drug,” and there is no generic or interchangeable drug, your plan will reimburse you the cost* of the brand-name drug.
• If there is a generic drug and you choose to buy the brand-name drug, your plan will reimburse you the cost* of the generic drug only.
• In some instances, you may experience an adverse reaction to the generic drug, or it is therapeutically ineffective. When this happens, medical evidence can be submitted to support why the brand-name drug is being prescribed. To get approved for a brand-name drug, you need to complete the Request for Approval of Brand-Name Drug form (www.otip.com/forms), have it signed by your doctor and return it to the address on the form. If approved, you will be paid back the cost* of the brand-name drug.

*Reasonable and customary will be applied to the eligible amount

Here’s an example¹ of how mandatory generic substitution works:

When filling a prescription – speak up!

In many provinces, pharmacists will automatically dispense the generic alternative as part of their standard practice unless the prescribing doctor has indicated that “no substitutions” should be made. If your doctor has indicated “no substitution,” you can ask your pharmacist to dispense the generic drug – or you can accept the brand-name drug, and pay the price difference between the brand-name and the generic drugs.

If you share in either the cost of your plan or the cost of your prescription, switching to generics may help you and your plan save some money!

Use My drug plan to look for generic drug options

My drug plan is a user-friendly, drug lookup tool (found in My Claims quick links). It can help you to manage your drug costs especially because you have a mandatory generic drug plan. You can find out if a generic drug is available or if prior authorization is needed. A drug library is also right at your fingertips.

IMPORTANT NOTES:

• Drug costs seen in My drug plan are estimates only.
• With a mandatory generic drug plan, any prescribed drug cost cannot exceed the price of the lower cost
  alternative drug, which is typically a “generic” drug.
  • If the drug you are prescribed is a “brand-name drug,” and there is no generic or interchangeable drug, your plan will reimburse* you the cost of the brand-name drug.
  • If there is a generic drug and you choose to buy the brand-name drug, your plan will reimburse* you the cost of the generic drug.

In some instances, you may experience an adverse reaction to the generic drug, or it is therapeutically ineffective. When this happens, medical evidence can be submitted to support why the brand-name drug is being prescribed. To get approved for a brand-name drug, you need to complete the Request for Approval of Brand-Name Drug form, have it signed by your doctor and return it to the address on the form. If approved, you will be paid back* the cost of the brand-name drug.

*Before you get any money back, reasonable and customary limitations, coinsurance\reimbursement, deductibles and/or maximums apply as per the terms and conditions in each plan (refer to your benefits booklet).

Myth: Brand-name drugs are safer and more effective than generic drugs.

Fact: Generic drugs are every bit as safe and effective as brand-name drugs. In fact, they are equivalent to the brand version in dosage, safety, strength, quality, the way they work and the way they’re taken.

Brand-name and generic drugs have one important thing in common: they’re designed to heal us or make us feel better. And one of the big differences between these drugs is the cost. To help manage drug costs while ensuring you and your family have access to appropriate drug therapy, your benefits plan includes mandatory generic substitution.

What is a generic drug?

Generics are similar, not identical, to brand-name drugs.

When a new drug is developed, found to be safe and effective, and finally approved, it’s usually patented. The patent protects the new drug from being copied for a period of 20 years. The new drug is marketed and sold only by the pharmaceutical company that developed it. When the patent-protected period ends, other companies can produce and sell the same drug as generic equivalents. Because the brand-name drug has already been proven, companies can save research and development costs and afford to charge less for the generic drug.

There may be many generic versions of the brand-name drug. Next time you are prescribed a drug by your doctor or visit your pharmacist to fill a prescription, consider asking the following questions:

• Is this prescription for a generic drug?
• Is there a generic version of my drug available?
• Can I substitute my drug with the generic version?
• How much will I save under my plan if I switch to a generic drug?

Win-win situation: Your plan and generic drugs

With mandatory generic substitution in your drug plan, any prescribed drug cost cannot be more than the price of the lower cost alternative drug (generic drug).

• If you are prescribed a brand-name drug, and there is no generic or interchangeable drug, your plan will reimburse you the cost of the brand-name drug.
• If there is a generic drug and you choose to buy the brand-name drug, your plan will reimburse you the cost of the generic drug only.

In some instances, you may experience an adverse reaction to the generic drug, or it is therapeutically ineffective. When this happens, medical evidence can be submitted to support why the brand-name drug is being prescribed. To get approved for a brand-name drug, you need to complete the Request for Approval of Brand-Name Drug form (www.otip.com/forms), have it signed by your doctor and return it to the address on the form. If approved, you will be paid back the cost of the brand-name drug.

Check your benefits booklet to learn more about your drug coverage or call OTIP Benefits Services at 1- 866-783-6847.

Sources:

http://www.choosinggenerics.ca

The Safety and Effectives of Generic Drugs, Government of Canada, https://www.canada.ca/en/healthcanada/services/healthy-living/your-health/medical-information/safety-effectiveness-generic-drugs.html, 2012

To ensure you get a suitable custom-made orthotic, it’s important to ask questions and keep yourself informed throughout the purchasing process.

Under the OSSTF Benefits Plan, your coverage for casted, customer-made orthotics is: up to a maximum of $750 per plan year (an approved diagnosis from either a physician or a podiatrist/chiropodist is required.) The plan year is September to August.

Who’s authorized to prescribe and complete an assessment?

Custom-made orthotics are prescribed by specific health-care professionals, which include physicians, podiatrists and chiropodists. They will diagnose whether or not an orthotic would be beneficial to your situation. The prescribers and providers are licensed and governed by either a provincial or national body, and are subject to standards of practice. This, along with each body’s Code of Ethics, helps ensure their accountability and your protection.

For all Canadian provinces, except Quebec*, podiatrists, chiropodists, pedorthists are recognized as foot care specialists.

After being prescribed an orthotic, you’ll need to visit one of the providers listed above for an assessment. A provider will guide you through an extensive evaluation to ensure an orthotic is the best option and that it’s properly designed. You should expect the orthotic provider to perform the following:

Medical history review: A complete investigation and documentation of your medical history, symptoms and previous injuries. The provider will also take into consideration your lifestyle (occupation and activities) as well as your current and past footwear (fit, style, wear and pattern).

Examination: A hands-on evaluation of the lower limbs including foot structure, alignment, strength, range of motion, soft-tissue damage as well as identifying any abnormalities.

Gait analysis: The provider will observe you walking to identify accommodations or abnormalities (e.g. whether you favour one leg or the other).

Orthotic evaluation: The provider will determine treatment options and explain how the treatments will address your specific needs.

Casting: A proper cast is essential to create a truly custom-made orthotic as it ensures that your orthotic is made with all of the contours and structure of your foot. Casting techniques include: foam box casting, plaster of paris slipper casting, contact digitizing and laser scanning.

Manufacturing: For an orthotic to be claimed under your benefits plan, it must be constructed from scratch and fabricated directly from your mould. You can expect at least one week between your initial assessment and your fitting appointments. Orthotics that are not manufactured specifically to your needs can result in pain by overstressing your muscles, bones and joints.

Dispensing: Custom-made orthotics should be fitted specifically for you and your footwear. The provider should evaluate how you walk while wearing the orthotics. You should also be offered a follow-up appointment within 2-6 weeks of receiving your orthotics.

Education: The provider should educate you on things like breaking in your new orthotics, lifespan, and how they should fit. You should also be made aware of any warning signs that the orthotics are not working properly and instructed to return if you experience any problems.

Here are some things to be cautious of when buying an orthotic:

• For all Canadian provinces except Quebec*, prescribers and providers should have the following designations in their titles:
  • Physician – M.D.
  • Podiatrist – D.P.M.
  • Chiropodist – D. Ch. or D. Pod. M.
  • Pedorthist – C. Ped. (C). or C. Ped. (M.C.)
  • Orthotist – C.O. (C) or C.P.O. (C)
• Under the OSSTF Benefits Plan, casted, custom-made orthotics must be recommended by a physician or podiatrist/chiropodist.
• Question a provider who strongly recommends you see a doctor of his or her choosing for a referral instead of your family physician.
• Question a provider who recommends your whole family could benefit from orthotics without having seen or assessed them individually.
• Be suspicious of any provider that can’t answer your questions clearly or gives vague and ambiguous answers.
• Having your footprint taken on an inkpad or using your shoe size to provide a prefabricated insole is not considered casting and does not qualify as custom-made.
• Some providers will supply what’s called a “best fit” foot bed. These are prefabricated inserts that are matched to your cast; however, the cast is never used in the actual manufacturing of the orthotic. These are not considered custom-made and would not qualify under your benefit plan.
• A provider should have the capacity to modify your orthotic.
• Exercise caution when considering the purchase of orthotics from exhibits at trade shows, home shows or sportsman shows. If there’s a problem with the orthotic, returning it could be a problem, not to mention they probably aren’t custom-made. Exercise caution when considering the purchase from kiosks or booths in malls, department stores or over the internet for the same reasons.
• Be wary of people who come to your home, or conduct group screenings of employees or family members without a proper evaluation.
• “Two for the price of one” deals or “free giveaways” with your purchase are not allowed under the code of ethics that regulated providers and dispensers are bound by. Some providers will use these “freebies” to inflate the price of an orthotic.
• Custom-made orthotics for children under five are highly uncommon. Skeletal or soft tissue injuries that require orthotic treatment don’t usually present themselves until a person is older. If for some reason they do need an orthotic, a medical doctor or pediatric specialist must prescribe it.
• If you feel pressured to purchase additional products or are uncomfortable with the business practices of the provider, consider another provider.
• Don’t ever give the provider a signed claim form.

Please note that some of the examples listed above may not pertain to your benefits plan. Consult your benefits booklet for details.

*For the province of Quebec a foot orthotist or an orthotist prosthetist working in a laboratory accredited by the Québec Ministry of Health and Social Services and who is a member of the Order of Professional Technologists of Quebec and a podiatrist are the eligible providers of orthotics.

The 2017-2018 Annual Report is now available by clicking here (3MB PDF).

• Report of the Chair
• Transition into the OSSTF ELHT Benefits Plan
• Utilization of the Plan
• 2017 Financial Information
• Annual Renewal of the OSSTF ELHT

September 1 was the first financial renewal of the OSSTF Benefits Plan. Future renewals are scheduled for each September 1st going forward; however, rate and/or plan design changes can be implemented at any time throughout the benefit year, in order to sustain the plan over the long term.

The Trustees of the OSSTF ELHT have been working with OTIP (the Third-Party Administrator), Manulife (the provider of the life insurance, health and dental benefits) and Teachers Life (the provider of the Accidental Death and Dismemberment Benefits) to set the benefit rates as of September 1, 2018.

The Trustees approved the following changes at time of renewal:

• A reduction of 10% to the Basic Life Insurance Rate. For active members, the life insurance premium is funded through the negotiated FTE funding—this will not have an impact on member contributions, although it will result in a slight decrease to the T4As issued annually for the taxable life insurance premium.
• The rates for all other benefits, (i.e. the Basic Accidental Death and Dismemberment), Optional Life, Optional Accidental Death and Dismemberment, and Health and Dental) will be unchanged through this renewal. There will be no change to member contributions towards these benefits for both active members and those on leave who are participating in the plan.

As the plan matures, the OSSTF ELHT will be better able to assess claim patterns. The current claims experience of the OSSTF ELHT for health and dental benefits reflects higher than anticipated claiming patterns by members. If these high claiming patterns continue, it may be necessary to increase the rates and member contributions towards the benefits and/or to implement cost containment strategies into the plan prior to, or at next renewal.

The OSSTF ELHT was negotiated for OSSTF members. It provides a full and comprehensive benefits program to cover the health needs of members and their dependents. The long-term sustainability of the plan is one of the OSSTF ELHT’s major priorities so it is important that members are aware of these potential future challenges.

If you have any questions please contact Donna Morrison, Executive Director at donna.morrison@osstfbenefits.ca.

The OSSTF Benefits Plan provides Life Insurance, AD&D (Accidental Death and Dismemberment) and Health and Dental benefits for eligible members. The funding for the Basic Life Insurance and AD&D in the OSSTF Benefits Plan for active members is fully paid from the negotiated Full Time Equivalent Funding with no member contribution required for these benefits. This funding; therefore, is a taxable benefit to OSSTF members which means members will receive a T4A annually from OTIP for this taxable benefit.

In order to issue the T4A for this taxable benefit, OTIP requires that Social Insurance Numbers are provided by the School Boards and School Authorities once a year.

You should be receiving a letter from your School Board or School Authority indicating that they are being required to provide your Social Insurance Number for the sole purpose of issuing this T4A annually.

As with all personal and financial information, please be assured that all involved parties have and will continue to treat this information with the utmost safety, security and confidentiality.

If you have any questions please contact Donna Morrison, Executive Director at donna.morrison@osstfbenefits.ca.

Life events – What they mean to you and your benefits coverage

In the insurance world, a life event simply means a change in your personal situation that can make you eligible for a special enrolment period in your group health, dental and life benefits plan.

Events, like marriage, the birth of a baby, adoption or legal custody of a child, divorce, the death of a spouse/partner or dependant or a spouse/partner losing benefits coverage, might allow you to enrol, or change your current benefits coverage, providing you do so within a certain time frame (i.e. within 31 days).

For example, a member currently has single coverage and gets married or has a baby. Given this life event, the member can now change their coverage from single to family and add their new dependant to their benefits coverage, providing they do so within 31 days of the wedding, or the birth/adoption of the child.

In another example, a member may have turned down health and/or dental coverage during their enrolment because their spouse/partner had benefits. A few months later, their spouse loses that coverage due to a change in employment, or maybe passes away. This would entitle the member to a special enrolment period where they could add coverage for health and/or dental coverage, so long as the enrolment was completed within the required timeframe of 31 days.

How do you make life event changes to your benefits coverage?

Making life event changes is easier than ever using OTIP’s secure member site.

1. Click Log in on the top-right of the website.
2. Select Health and Dental from the drop-down menu and log in.
3. After you have logged in, click My Benefits.
4. On My Benefits home page, click Enrol/Make Changes in the My Personal Info box.
5. Under the Life Event heading, click on the relevant Life Event (such as Adoption/Legal Custody of a Child, Marriage/Common-Law, or Death of a Dependant).
6. Follow the steps to update or add the requested information.
7. This must be completed within 31 days of the life event (marriage, birth, death, etc.)

What happens if you don’t make the changes within 31 days?

The 31-day window is your special enrolment period for life events. If you miss it, in other words you do not apply for benefits for yourself or an eligible dependant during that time, you are considered to be ‘a late entrant’. This means that you will be required to complete an Application for Insurance and Evidence of Insurability, which determines proof of good health. Therefore, it is critical that you make these important changes within the 31-day timeframe, otherwise coverage may be denied for you and/or your dependant.

OTIP is here to help! If you have questions about qualifying life events, or how to make changes to your benefits coverage, please contact OTIP Benefits Services at 1‑866‑783‑6847.

What are reasonable and customary (R&C) limits and how do they work?

R&C limits refer to the maximum allowable amount that an insurance carrier will reimburse on a particular service or item. This amount usually reflects the typical cost associated with this service or product in a specific geographical region.

R&C limits are most noticeable in paramedical practitioners (chiropractor, physiotherapist, massage therapist, etc.) and medical service providers. Why? Unlike physicians and hospital services, paramedical and medical service providers do not have to adhere to a provincial fee guide, and are instead free to charge whatever they choose for their services and supplies.

Let’s use an example. Sera hurts her back, and seeks the services of a chiropractor. This particular chiropractor charges $200 for an initial consultation; however, the R&C limit for this service in Ontario is $180. When Sera submits her claim, Manulife, our insurance carrier, will use their R&C limit to determine her claim reimbursement. In this case, Sera would be reimbursed $180, and would be out of pocket the other $20.

Why are R&C limits important?

Higher rates drive higher plan costs. R&C limits are important to ensure claims to your benefits plan are not excessive. Therefore, smart shopping on your part for health-care products and services helps by not only reducing your out-of-pocket expenses, but also helping to reduce benefits plan costs. R&C limits also help reduce the likelihood of benefits fraud or abuse. Together, this means a healthier plan with more sustainable benefits.

How do I find out what my R&C limits are?

To view Manulife’s R&C amounts:

1. Click Log in on the top-right corner of the website.
2. Select Health and Dental from the drop-down menu and log in to your account.
3. After you have logged in, click My Claims.
4. Click Practitioner R&C under the My benefits quick links.

Since R&C limits may change over time without notice, please review this information before starting a new medical treatment, or using a new paramedical or medical service provider. OTIP is also here to help. If you have questions about R&C limits, or how they might impact you, call OTIP at 1‑866‑783‑6847.

Did you know under the OSSTF Benefits Plan, your coverage for surgical stockings is: up to a maximum of six (6) pairs per plan year on a reasonable and customary basis? The plan year is September to August.

To avoid delays in processing your surgical stocking claims, please complete and sign the Extended Health Care Claim form and attach the following information:

From the physician/podiatrist:

1. Diagnosis necessitating the surgical stockings (A medical referral is not a diagnosis and will be insufficient. A separate diagnosis in addition to the medical referral is required.)
2. Description of what activities the surgical stockings will be primarily worn for (daily living, sports, etc.)
3. Anticipated duration the surgical stockings will be required
4. Verification if this is an initial purchase or reason for replacement

From the supplier:

1. Itemized receipt including patient name, date of service and total amount of purchase
2. Confirmation whether or not the surgical stockings are eligible for funding through a provincial plan (if “yes” and applicable, a copy of the provincial plan’s statement of payment is required)
3. Make, model and style of the stockings (style: knee-high or full-length)
4. Confirmation if the stockings are custom-made or off-the-shelf
5. Gradient factor

Ensure all applicable sections of the claim form are completed and include copies of primary payment if coordination of benefits (COB) is required. Please send this information as instructed on the form.

NOTES:

• It is strongly recommended a pre-determination be submitted prior to incurring expenses to ensure eligibility.
• Any costs associated in obtaining the above information will be the responsibility of the patient. In some situations, we may request further information in order to confirm eligibility.

DID YOU KNOW?

If you have either lymphedema or a hypertrophic scar, you can apply for coverage with the Assistive Devices Program (ADP).

ADP’s allowance is 75% of the cost of:

• Lymphedema compression stockings: 3 pairs over a 2-year period
• Hypertrophic scar pressure stockings: 5 pairs over a 2-year period

NOTE: Varicose veins, diabetes, thromboses are not eligible under the ADP.

To apply to the ADP, please work with your service provider. If the ADP does not cover the full cost of your expense, you can submit the remainder to OSSTF Benefits Plan via My Claims or completing the Extended Health Benefit Claim form (776kB PDF).

Questions about the ADP? You can learn more at: Garments, pumps and braces.

We are pleased to announce that your OSSTF Benefits Plan now includes psychotherapy.

What is Psychotherapy?

Psychotherapy is a term that covers all talking therapies and the many associated approaches/methods. Psychotherapists are mental health professionals who use “talking therapy” or counselling to help people work through difficult issues, rather than medications or physical interventions. People generally see psychotherapists when their problems affect their day-to-day living.

What is the benefits coverage?

Psychotherapy will be added to your plan at 100% coverage up to $2,000 per Plan Year combined for services of a psychologist, marriage and family therapist, social worker and psychotherapist. All psychotherapists must be licensed and registered in the province of coverage and all claims are subject to reasonable and customary charges.

Additional questions? For more detailed information on this new benefit, please review your benefits booklet located in My Claims. If you have any questions about your benefits plan, or if a claim would be eligible for coverage, please contact OTIP Benefits Services at 1-866-783-6847.