Undergraduate Health Care Plan

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Canadian Federation of Students
Royal Roads University Students’ Union – F/T Students
Billing Division No. 23787
 
GREEN SHIELD 
OUTLINE OF BENEFITS      
 
Services shown below will be eligible if they are usual, reasonable and customary, and are medically necessary for the treatment of an illness or injury. Please contact the Green Shield Customer Service Centre at 1-888-711-1119 or the National Student Health Network at 1-800-468-0668 to determine benefit eligibility and coverage details. Inquiries can also be emailed through the Green Shield Canada website, www.greenshield.ca. Visit the “Contact Us” – Customer Service section.
 
Students with dependents may upgrade to family coverage by remitting the appropriate premium. Dependents include common-law/same sex spouse with whom the student has been living in a conjugal relationship for a period of 12 months.
 
Dependent children are eligible for coverage up to the end of the Benefit Year in which they turn 21; or age 25 if enrolled and in full-time attendance at an accredited college, university or education institute.
 
“Co-payment” means the amount that you are required to pay.
“Co-insurance” means the percentage of the eligible amount that you are entitled to receive after satisfaction of the deductible.
“Benefit Year” means the period of September 1 until August 31.
 
 
DRUGS      
  • A dispensing fee cap of $3 applies to each prescription
  • Your Drug co-insurance is 80 per cent of the cost (i.e., you are responsible for 20 per cent of the cost)
  • Reimbursement will be based on the lowest priced generic equivalent
Benefits include drugs legally requiring a prescription by law, diabetic needles and syringes.
 
Benefits do not include medication for the treatment of anti-obesity, smoking cessation products, erectile dysfunction, hair loss and/or hair replacement, and fertility. Serums and vitamins are also ineligible unless injected and medically necessary.
 
HEALTH SERVICES
  • Your overall Health deductible is $10 Single or $10 Family per Benefit year (Sept.1 to Aug. 31).
  • Deductibles apply to Drug, Emergency Transportation, Medical Items, Paramedical Services, and Dental Accident.
  • Your co-insurance for Health Services is 100 per cent of the cost with the exception of Paramedical Services, Contraceptive Devices, Incontinence Supplies, and Ostomy Supplies which are reimbursed at 80 per cent of the cost (i.e., you are responsible for 20 per cent of the costs).
EMERGENCY TRANSPORTATION
Ambulance Transportation, for land or air ambulance to the nearest hospital equipped to provide the required treatment.
 
ACCIDENTAL DENTAL BENEFITS
Accidental Dental benefits for treatment by a dentist. A dental accident report form must be submitted immediately following the accident.
 
MEDICAL ITEMS
Prosthetic Appliances and Durable Medical Equipment, as well as replacements, repairs, fittings and adjustments of such devices. Contact the Customer Service Centre to verify eligibility of a particular benefit.
 
PARAMEDICAL SERVICES    
Physiotherapist, Chiropractor, Podiatrist/Chiropodist, Naturopath, Registered Massage Therapist, Speech Therapist, Athletic Therapist, and Acupuncturist: up to a maximum of $250 per paramedical discipline per Benefit Year (Sept. 1 to Aug. 31).
 
Psychologist up to a maximum of $500 per Benefit Year (Sept. 1 to Aug. 31).
 
Note:
Services of a Physiotherapist, Podiatrist/Chiropodist, Naturopath, Registered Massage Therapist, Speech Therapist, Athletic Therapist, Acupuncturist, or Psychologist are only covered when authorized in writing by a physician.
Chiropractic and/or Podiatry Services are not eligible until your Provincial health insurance plan annual maximum has been exhausted.
 
Paramedical services are only eligible when the practitioner rendering the service is licensed by their provincial association and that association is recognized by Green Shield Canada. Please contact the Green Shield Customer Service Centre to confirm eligibility when in doubt.
 
TUTORIAL BENEFITS   
  • Your co-insurance for Tutorial Services is 100 per cent.
  • Your maximum of $1000 per disability.
  • Private tutorial service of a qualified teacher up to $15 per hour, if an accident or illness causes you to be disabled and confined to home or hospital for fifteen consecutive school days. 
Note: Your dependants are not eligible for this benefit.
 
EYE EXAMINATIONS
Eye examinations performed by a licenses Optometrist limited to a maximum of $25 every 24 months beginning Sept. 1.
 
Preferred Provider Vision Network Arrangement
As a Green Shield Plan Member, you have access to our national preferred provider vision network arrangement where all Green Shield Plan Members are eligible to receive a discount on eyewear.
 
Features of this great value added service include:
  • Offer applies to any Green Shield Plan Member, regardless of whether you have Green Shield vision benefits or not
  • The vision provider may bill Green Shield directly, the Plan Member just pays any portion of the expense not covered under their vision benefit
  • Trustworthy retail chains in convenient locations
  • Discount offer applies to everything such as all extra coatings, upgrades and accessories
  • Hundreds of the latest frame styles to choose from plus the latest lens and coating technology
  • Professional opticians to assist in selecting products
  • Offer applies to non-disposable contact lenses (excludes disposable contact lenses).
Visit our website at www.greenshield.ca or call our Customer Service Centre at 1-888-711-1119 for information on the vision providers.
 
How to submit your Vision Claim    
  1. Present your Green Shield identification card as proof of being a Green Shield Plan Member
  2. The vision provider will apply the appropriate discount(s) to your claim and may submit the claim directly to Green Shield for payment. You pay your vision provider any balance not covered under your vision benefit
  3. If no vision benefit exists, you pay your provider the full balance owing after the applicable discounts have been applied.
DENTAL
  • Your deductible is nil
  • Your overall Dental maximum is $500 per benefit year (Sept. 1 to Aug. 31) or 50 per cent if the student enrols in the plan in the month of March or later
  • Your co-insurance is 70 per cent for Basic Services, and Comprehensive Basic Services
  • Basic services cover: recalls once every five (5) months. Other exams and full mouth x-rays every three years
  • Comprehensive basic services cover denture relines once per benefit year (Sept. 1 to Aug. 31)
  • Applicable lab, drug and other expenses are eligible to a maximum of 40 per cent of the allowable professional fee. Any applicable co-payment is then applied.
  • Your eligible claims are reimbursed at the level stated above and in accordance with the Current Provincial Dental Association Fee Guide for General Practitioners.
Basic Dental Services
  • Recalls include exams, bitewing X-rays, cleanings and fluoride treatments.
  • Complete, general or comprehensive oral exams, full mouth X-rays and panoramic X-rays.
  • Basic restorations, fillings and inlays.
  • Extractions and surgical services, including wisdom tooth extraction. General anaesthetics and intravenous sedation only when done in conjunction with eligible extraction(s) and/or oral surgery. Sleep dentistry is not eligible.
Comprehensive Basic Services
  • Periodontal treatment including scaling and/or root planning
  • Endodontic treatment including root canal therapy.  
 
GENERAL INFORMATION
 
OUR COMMITMENT TO PRIVACY
The Green Shield Canada Privacy Code balances the privacy rights of our group and benefit plan participants, and our employees, with the legitimate information requirements to provide customer service and to meet our human resource requirements. It consists of the following key principles:
 
1. We ask for your personal information for the following purposes:
  • To establish your identification
  • To provide you and/or your dependents with the applicable benefit coverage
  • To protect you and us from error and fraud
  • To provide ongoing access to other services at Green Shield
 
2. Consent
When you enrolled in your group benefit plan as a plan participant, your personal information was obtained and used only with your consent. We obtained your consent before we:
  • Provided benefit coverage
  • Offered you other Green Shield Canada services
  • Obtained, used, or disclosed to other persons, information about you unless we were obliged to do so by law or to protect our interests
  • Used your personal information in any way we did not tell you about previously
 
Your consent can be either express or implied. Expressed consent can be verbal or written.
 
Consent can be implied or inferred from certain actions. For our existing group and benefit plan participants, we will continue to use and disclose your personal information previously collected in accordance with our current privacy code, unless you inform us otherwise and will infer that consent has been obtained by your continued use.
 
3. Withdrawal of Consent
You can withdraw your consent any time after you’ve given it to us, provided there are no legal or regulatory requirements to prevent this.
 
If you don’t consent to certain uses of personal information, or if you withdraw your consent, we will no longer be able to administer your benefit coverage. If so, we will explain the situation to you to help you with your decision.
 
For further information on our privacy policies and procedures, please refer to the Green Shield Canada website at www.greenshield.ca.
 
LIMITED BENEFIT CLAUSE
Green Shield will determine the amount of benefits payable, giving consideration to limited procedures, services or courses of treatment that may be performed to accomplish the desired result. The attending physician/dentist and the patient have the option of which procedure to use, although payment for the procedure may be based on the “limited treatment” principle. The Limited Benefit Clause is a financial limitation and not intended as a comment regarding any treatment recommended or performed by a physician/dentist.
 
PREDETERMINATION
If the cost of any proposed treatment is expected to exceed $300, submit to Green Shield a detailed treatment plan from your provider before your treatment begins. If a description of the procedures to be performed and an estimate of the charges are not submitted in advance, Green Shield reserves the right to make a determination of benefits payable, taking into account alternate procedures, services, or course of treatment, based on accepted standards of medical/dental practice.
 
GENERAL OVERALL EXCLUSIONS
 
Eligible Services 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:
  1. intentionally self-inflicted injury while sane or insane;
  2. an act of ware, declared or undeclared;
  3. participation in a riot or civil commotion; or
  4. 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:
  1. 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 Canada’s approved indication for use)
  2. is an adjunctive drug prescribed in connection with any treatment or drug that is not an eligible service
  3. will be administered in a hospital
  4. is not dispensed by a pharmacist in accordance with the payment method used for Drugs
  5. 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.       Services or supplies that,
  1. 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
  2. are legally prohibited by the government by coverage
  3. you 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 party other than Green Shield, your plan sponsor or you
  4. are provided by a health practitioner whose license by the relevant provincial regulatory and/or professional association has been suspended or revoked
  5. are not provided by a designated provided of service in response to a prescription issued by a legally qualified health provider
  6. are primarily for cosmetic or aesthetic purposes, or are to correct congenital malformations
  7. are 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
  8. are a replacement for lost, missing, or stolen items, or items that are damaged due to negligence
  9. are from any governmental agency which are obtained without cost by compliance with laws and regulations enacted by a federal, provincial, municipal, or other governmental body
  10. would normally be paid through any provincial health insurance plan, worker’s compensation 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 had been made, or had proper and timely claims submission been made
  11. were previously provided or paid for by any governmental body or agency, but which have been modified, suspended, or discontinued as result of changes in provincial health plan legislation or de-listing of any provincial health plan services or supplies
  12. 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)
  13. are provided by a medical practitioner who has opted out of any provincial health insurance plan and the provincial health insurance plan would have otherwise paid for such eligible service
  14. relates to treatment of injuries arising out of motor vehicle accident
  15. are cognitive or administrative services of other fees charge by a provider of service for services other than those directly relating to the delivery of the service or supply.
CO-ORDINATION OF BENEFITS (COB)
Where you or your dependents have coverage with more than one carrier, claims shall be coordinated so that reimbursement from all coverage shall not exceed 100 per cent of the actual claim. Ask for our COB brochure for information on how your family can receive this service.
 
PLAN MEMBER ON LINE SERVICES
For plan members, (ID card number ends with -00, this site will answer those questions most often asked and give online access to the following:
  • Print personalized claim forms
  • Find out benefit eligibility information, like when you can buy your next pair of glasses
  • Instantly view your Explanation of Benefits and claim history
  • Print your own history for tax purposes and Co-ordination of Benefits
  • Have claim payments deposited directly into your bank account
  • And much more!
Contact the Green Shield Canada Customer Service Centre at 1-888-711-1119 to confirm your permanent address is entered on our system. You can then self-register for Plan Member Online Services using your Green Shield ID number (RRU000 + your 6 digit student number + 00) and Green Shield will mail the logon and password information required to activate your account. Visit www.greenshield.ca today.
 
Please note, that once arrangements have been made for Direct Deposit, claim payments will be deposited directly into the bank account you have chosen. Statements will no longer be mailed to you but will be available for online viewing.
 
SUBROGATION
Green Shield retains the right to subrogation if benefits have or should have been paid or provided by a third party. In cases of third party liability, you must advise your lawyer of these rights.
 
GROUP CONVERSION – PRISM CONTINUUM™ PROGRAM
The PRISM CONTINUUM™ Program offers three plans that are focused on providing coverage for you if you are leaving a company group plan.
 
This program may be your solution if you, your spouse, or dependent children, are losing or have lost company group health benefits within the last sixty (60) days and are looking for guaranteed coverage.
 
Call 416-601-0429 in the Toronto area, or toll free at 1-800-667-0429 for an information package or visit our website at www.greenshield.ca. Coverage is guaranteed if you apply within 60 days of losing your Green Shield group benefits.
 
                                                                                      June 2008  
 
Contact Information:   
 
Green Shield Canada
Customer Service Centre: 1-888-711-1119 (Toll Free)
General Information: www.greenshield.ca
National Student Health Network: 1-800-468-0668