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Extended Health Care
The Extended Health Care (EHC) plan is designed to help you pay for specified services and supplies incurred by you and your Dependents, when not provided under a government health plan or by a tax supported agency.
Definitions
Eligible expense
means a charge for any service and/or supply included in this booklet as a benefit that:
- in our assessment is a customary charge medically necessary for health care and maintenance, or to maintain or restore teeth, and
- was ordered or referred by a Physician or Dentist, unless otherwise specified in the benefit description, and
- is not a cost normally paid (in whole or part) or provided by a government plan or any other provider of health coverage, and
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is incurred while your coverage is valid. An expense is "incurred" on the date the service is provided or the supply is received.
It does not include any payment to a pharmacy or a Practitioner (demanded or received by balanced billing, extra billing, or extra charging) which represents an amount in excess of the schedule of costs prescribed by the government plan. PharmaCare’s low cost alternative and reference based pricing will not be applied unless specified in this booklet. Physician
means an individual who is duly qualified and licensed to practice medicine or surgery, or both, in the area where the service is provided.
Practitioner
means an individual who is currently licensed, certified, or registered to practice a profession in the area where the care or service is provided.
In-Province Eligible Expenses
Your EHC plan covers reasonable and customary charges for the following services and supplies when medically necessary, and prescribed, ordered, or referred by a Physician. Unless otherwise indicated, the maximums included here are on a per person basis.
- Hospital
a) the additional charge for private or semi private room accommodation in a hospital, and
b) out-patient charges when not covered under a government plan, and
c) the additional charge for accommodation incurred in a convalescent facility or nursing home, to a maximum of $20 per day for 120 days for any one illness or injury. Admission to the convalescent facility/nursing home must occur within 48 hours of discharge from the hospital where the patient was confined for the same illness or injury for at least 5 days, and
d) nursing care rendered in the patient’s home by a registered nursing assistant, to a maximum of $10 per day for 120 days for any one illness or injury. Nursing care in the patient’s home must occur within 48 hours of discharge from the hospital where the patient was confined for the same illness or injury for at least 5 days.
Charges for rental of a telephone, television, or similar equipment are not covered.
- Emergency ambulance
a) charges for licensed ambulance service to and from the nearest Canadian hospital equipped to provide the type of care essential to the patient
b) air transport will be covered when time is critical and the patient's physical condition prevents the use of another means of transport
c) emergency transport from one hospital to another, only when the original hospital has inadequate facilities
d) charges for an attendant when medically necessary.
- Drugs
Drugs and medicines dispensed by a licensed pharmacist or a Physician, limited to a 3 month supply at any one time:
a) drugs and medicines which legally require a prescription from a Physician or Dentist, and included with the above:
i) contraceptives
ii) vaccines
iii) erectile dysfunction drugs
b) insulin preparations, testing supplies, needles, and syringes for diabetics
c) vitamin B12 for the treatment of pernicious anemia
d) allergy serums when administered by a Physician.
- Practitioners
Professional services of the following Practitioners to the maximum amounts indicated per calendar year, but excluding appliances and tray fees. Only the services of a private duty nurse require referral by a Physician.
a) acupuncturist $600
b) chiropractor and chiropractic x-rays combined $600
c) massage practitioner $600
d) naturopath and x-rays combined $600
e) osteopath and osteopath x-rays combined $600
f) physiotherapist no calendar year limit
g) podiatrist and podiatrist x-rays combined $600
h) psychologist and social worker* combined $600
i) speech language pathologist $600
j) private duty care by a registered nurse for a person with an acute condition in the person’s home in the patient’s province of residence to a maximum of $25,000.
*To be eligible under this plan, a social worker must hold a masters degree.
- Dental Accident
Dental treatment by a Dentist, which is required, performed, and completed within 52 weeks after an Accidental injury which occurred while covered under this EHC plan, for the repair or replacement of natural teeth or prosthetics. No payment will be made for temporary, duplicate, or incomplete procedures, or for correcting unsuccessful procedures.
Accidental
means caused by a direct external blow to the mouth or face resulting in immediate damage to the natural teeth or prosthetics and not by an object intentionally or unintentionally being placed in the mouth.
We pay benefits based on eligible dental services and financial limits in our current Fee Schedule, and we pay the fees in the applicable Fee Guide of the province/territory of service.
- Medical aids and supplies
Charges for the following services and supplies:
a) oxygen, blood, and blood plasma
b) laboratory tests and diagnostic services when not covered under a government plan
c) intrauterine devices and diaphragms
d) ostomy and ileostomy supplies
e) walkers, canes and cane tips, crutches, splints, casts, collars, and trusses, but not elastic or foam supports
f) rigid support braces and permanent prostheses (artificial eyes, limbs, larynxes, and mastectomy forms).
g) mastectomy brassieres and surgical stockings
h) stump socks to a calendar year maximum of 6 pairs
i) wigs and hairpieces required as a result of medical treatment, injury, alopecia areata, alopecia universalis or alopecia totalis to a maximum of $100 in a 6 month period
j) orthopedic shoes and orthotics
i) when prescribed by a Physician, podiatrist, or chiropractor as medically necessary after diagnosis of the patient, custom made orthopedic shoes (including repairs) and modifications to stock item footwear. A custom made orthopedic shoe is one fabricated from raw materials and specifically designed for the patient, based on a three-dimensional volumetric model of the patient’s foot and lower leg
ii) when prescribed by a Physician, podiatrist, chiropractor, or physiotherapist as medically necessary after diagnosis (including an in person biomechanical assessment) of the patient, custom made orthotics to a calendar year maximum of $200. A custom made orthotic is one fabricated from raw materials using a three-dimensional volumetric model of the patient’s feet
k) hearing aids and repairs (including batteries) to a maximum of $600 in a 5 calendar year period. Recharging devices and other such accessories are not covered. Replacement will be covered only when the hearing aid cannot be repaired satisfactorily.
- Standard durable medical equipment
a) Preauthorization may be required from us for items i) to vii) below.
b) Charges for standard durable medical equipment when rented from a medical supplier. If unavailable on a rental basis, or required for a long term disability, purchase of these items from a provider may be considered.
c) Repairs to purchased items. We will replace the item when it can no longer be made functional. We may request trade in or return of replaced equipment.
d) Reimbursement on rental equipment will be made monthly and will in no case exceed the total purchase price of similar equipment.
e) Standard durable equipment includes:
i) manual wheelchairs, manual type hospital beds, and necessary accessories – electric wheelchairs and hospital beds will be covered only when the patient is incapable of operating a manual wheelchair, otherwise we will pay the manual equivalent
ii) medical heart and blood glucose monitors, and cardiac screeners
iii) bi osteogen systems (when recommended by an orthopedic surgeon) and growth guidance systems
iv) breathing machines and appliances including respirators, compressors, percussors, suction pumps, oxygen cylinders, masks, and regulators
v) insulin infusion pumps for diabetics – when basic methods are not feasible
vi) transcutaneous electric nerve stimulators (TENS) when prescribed for intractable pain
vii) transcutaneous electric muscle stimulators (TEMS) required when, due to an injury or illness, all muscle tone has been lost.
- Vision Care
Charges for the purchase of eyewear or contact lenses when prescribed by a Physician or optometrist and/or repair of eyewear and charges for contact lens fittings when performed by a Physician or optometrist to a maximum of:
a) $200 per calendar year for Dependent children, and
b) $200 every 2 calendar years for members and Spouses.
Charges for non prescription eyewear are not covered.
- Visual Training
Charges for visual/remedial training when ordered by a Physician or optometrist to a maximum of:
a) 50% of the actual charges to a maximum of $200 per calendar year for Dependent children, and
b) 50% of the actual charges to a maximum of $200 every 2 calendar years for members and Spouses.
- Eye Examinations
Charges for routine eye examinations when performed by a Physician or optometrist for persons between the ages of 19 and 64 to a maximum of:
a) 1 examination per calendar year for Dependent children, and
b) 1 examination every 2 calendar years for members and Spouses.
Out-of-Canada Medical Referral
Benefits are payable for the following expenses incurred by you or your Dependent outside your province of residence:
- Hospital Benefits - while confined as a patient or treated in a hospital, the hospital room charge and charges for services and supplies over and above that covered by the government plan.
- Professional Services - charges for Physician's services, and laboratory and x-ray services when ordered by the attending Physician over and above the amount allowed under the regulations of the government plan.
Conditions and Limitations
- The treatment must by medically necessary, not available in Canada, and referred by a Physician resident in your province of residence.
- The government plan must authorize the treatment and accept the appropriate financial responsibility.
- Preauthorization is required from us.
- The maximum benefit for treatment outside Canada is 50% of the cost of treatment up to a maximum of $3,000 in a 3 calendar year period.
Out-of-Province Non-Emergency Eligible Expenses
We will reimburse you (and your Dependents) for non-emergency Eligible expenses incurred while travelling outside your province of residence subject to the Deductible, in-province reimbursement percentage, and maximums. We will not reimburse any expenses payable or provided under a government plan.
Out-of-Province Emergency Eligible Expenses
- While travelling outside your province of residence, benefits are payable for the following Eligible expenses incurred IN AN EMERGENCY ONLY and when ordered by the attending Physician. Non emergency continuing care, testing, treatment, and surgery, and amounts covered by any government plan and/or any other provider of health coverage are not eligible.
Local ambulance services when immediate transportation is required to the nearest hospital equipped to provide the treatment essential to the patient.
- The hospital room charge and charges for services and supplies when confined as a patient or treated in a hospital, to a maximum of 90 days.
If reasonably possible, we should be notified within 5 days of the patient's admission to hospital. When the patient's condition has stabilized, we have the right, with the approval of the attending Physician, to move the patient by licensed ambulance service to the hospital nearest the patient's home which is equipped and has space available to provide further medical treatment. Where transportation would endanger the patient's health, the 90 day limit may be extended with our expressed written consent.
- Services of a Physician and laboratory and x ray services.
- Prescription drugs in sufficient quantity to alleviate an acute medical condition.
- Other emergency services and/or supplies, if we would have covered them inside your province of residence.
- Charges, limited to the most economical means of transportation, for your Dependent child to his or her place of residence in Canada in the event you and/or your Spouse is hospitalized and your child is left unattended. Arrangements for an escort to accompany your child will be made, if necessary.
- Charges, limited to the cost of one-way economy fare air transportation, for the delay of the return trip of you or your Spouse due to the hospitalization of another insured person with whom you or your Spouse are travelling.
- Charges, limited to return economy fare air transportation, for one immediate family member to visit you or your Dependent if hospitalized. You or your Dependent must have been travelling alone and confined to a hospital for more than 7 days. An immediate family member is defined as a Spouse, child, parent, brother, sister, or a person with whom the insured person normally resides.
- Charges relating to items 6), 7) and 8) are limited to a combined maximum expense of $5,000 per family per medical emergency.
- Charges for accommodation for convalescence following hospitalization to a maximum of $75 per day per patient for a maximum of 5 days per medical emergency.
- Charges for commercial accommodation and meals for an immediate family member while staying with a hospitalized member or Dependent to a maximum of $100 per day up to 7 days per family per medical emergency.
Limitation:
Expenses only apply if the immediate family member had to travel to visit the patient, or if the immediate family member had to extend his or her stay beyond the scheduled date of his or her return trip.
- Charges relating to the return of your vehicle (excluding commercial transport vehicles) to your place of residence or the nearest appropriate rental agency in the event you are unable to return it due to a medical emergency to a maximum of $1,000 per medical emergency.
- Charges for the repatriation of a deceased member and/or Dependent to their place of residence to a maximum of $5,000.
We will only cover Eligible expenses obtained within 6 months of the date you or your Dependent left the country of residence. If hospitalization occurs within the 6 month period, in-patient services are covered until the date of discharge up to a maximum of 90 days. You and your Dependents are required to provide proof of the date of departure and return date to your country of residence, when requested by us.
Emergency Travel Assistance
In emergencies which occur while you (and your Dependents) are travelling, during the first 6 months after you initially leave your country of residence, medi-assist will coordinate the following services:
- locate the nearest appropriate medical care
- obtain consultative and advisory services and supervision of medical care by qualified licensed Physicians
- investigate, arrange and coordinate medical evacuations and related transportation needs
- arrange and coordinate the repatriation of remains
- replace lost or stolen passports, locate qualified legal assistance and local interpreters, and other incidental aid you and/or your Dependent may require when in distress.
Your Pacific Blue Cross worldwide emergency medi-assist card provides instant information on how to contact medi assist. Call the nearest medi assist emergency access number listed on your card. If necessary, call collect or contact the local telephone operator for help in placing your call to medi assist. Have your EHC ID number and medi assist group number ready for personal identification – both numbers are required.
Exclusions
The following are not included as Eligible expenses under your EHC plan:
- except as specifically included in this booklet: dentures or dental treatments, hearing aids, eyeglasses, contact lenses, surgical lens implants, or examinations for the prescription or fitting of any of these, x rays, hospital coinsurance, vitamins and/or minerals, contraceptives, fertility drugs, erectile dysfunction drugs, medications used to treat or replace an addiction or habituation, support stockings, orthotics, arch supports, transportation charges incurred for elective treatment and/or diagnostic procedures or for health or health examinations of any kind, and professional services of Physicians or any person who renders a professional health service in the patient's province of residence
- general anesthetic, medications used to prevent baldness or promote hair growth, food replacements or supplements, HCG injections, drugs not approved for sale and distribution in Canada, and medications available without a prescription
- any drug, vaccine, item or service classified as preventive treatment or administered for preventive purposes, and which is not specifically required for treatment of an illness or injury
- allergy testing unless rendered by a naturopath
- personal comfort items, items purchased for athletic use, air humidifiers and purifiers, services of Victorian Order of Nurses or graduate or licensed practical nurses, services of religious or spiritual healers, occupational therapy, services and supplies for cosmetic purposes, public ward accommodation, rest cures, and medical laboratory tests
- charges for communication costs, delivery and mailing or handling charges, interest or late payment charges, non sharable or capital costs levied by local hospitals, or charges for translating documents into English
- any payment to a pharmacy, a Practitioner, or a Physician (demanded or received by balanced billing, extra billing or extra charging) which represents an amount in excess of the schedule of costs prescribed by the government plan
- that portion of a claim normally covered by the government plan which has been refused on the basis that the claim was not submitted within the government plan's time limits
- expenses incurred, outside your province of residence, due to elective treatment and/or diagnostic procedures, or complications related to such treatment
- expenses incurred, outside your province of residence, due to therapeutic abortion, childbirth, or complications of pregnancy occurring within 2 months of the expected delivery date
- charges incurred outside your province of residence for continuous or routine medical care normally covered by the government plan in your province of residence
- expenses of a Dependent hospitalized at the time of enrolment
- services performed by a Physician who is related to or resident with you or your Spouse
- fees for ambulance services when an ambulance is called but not used
- ambulance charges for work related illness or injury assessed by the Workers' Compensation Board to be your employer’s responsibility
- retroactive coverage and payment of any expense, including expenses that receive special authorization from PharmaCare
- any other item not specifically included as a benefit.
Claims
Pay Direct
Provided your pharmacy is connected to our electronic processing system, we will pay them directly for prescription drugs and testing supplies for diabetics covered under your EHC plan. Simply show the pharmacist your EHC ID card. The pharmacist will charge you only for amounts not covered by us. If you or the pharmacy do not have access to this system, or for other types of expenses, please follow the instructions below.
Please Note: If your Spouse and/or children have coverage through another plan, your Pay Direct card cannot be used for their prescription expenses. Please refer to item 2 below for further information.
Paper Claims
- Because we do not return receipts after the claim is processed, we suggest that you keep a photocopy of the receipts that you submit to us. We will send you a remittance statement for your records each time you submit a claim.
- If you have Duplicate coverage, please review the Coordination of Benefits section under General Information. Two separate claim forms (one for the primary plan and one for the secondary plan) must be completed. The remittance statement from the first plan must be submitted to the second plan. Because claims information regarding the other plan is not retained on our files, be sure to provide information on the second plan on both claim forms. Incomplete claims will be returned for clarification.
- Certain medical expenses are covered under the government plan. If you submit your claim to us before you submit your claim to the government plan, we will deduct what the government plan would normally pay (e.g. PharmaCare expenses) from your EHC claim. The balance of the EHC claim is then paid according to the plan design. Information for claiming PharmaCare expenses may be obtained from your pharmacist.
- Accumulate receipts and when reasonable reimbursement is due, submit a claim as follows:
a) Obtain a claim form from your Plan Administrator.
b) Follow the instructions on the claim form. To avoid delay in claims payment, please include original receipts and all other requested information with your claim. (Photocopies of receipts are acceptable only when accompanied by a claims payment statement from another carrier).
c) We suggest you submit claims within 90 days from the date the expense was incurred. However, we must receive your claim by December 31st of the calendar year following the year in which the expense being claimed was incurred. If not, your claim will not be paid under any circumstances.
Example: We must receive your receipts for 2006 before December 31, 2007.
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