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Benefits You, April 2020

Benefits You, April 2020

Benefits You A publication of CAAT academic members of the Joint Insurance Committee (JIC)
Benefits You A publication of CAAT academic members of the Joint Insurance Committee (JIC)
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Click here to download the PDF of Benefits You, April 2020.

COVID-19 update

Your Benefits You newsletter was written prior to the COVID-19 pandemic.  In response to the emergency, Sun Life is offering many virtual services for our members.  Please refer to the Sun Life website for more information.  Stay safe and healthy!

Benefit news

At the Joint Insurance Committee, your OPSEU faculty advocates and staff work to assist you with benefits claims which have been denied. 

We are pleased to inform you that effective December 1, 2019, the Sun Life Benefits plan began covering Continuous Glucose Monitors: 

Coverage for continuous glucose monitor (CGM) supplies

Effective December 1, 2019, Continuous Glucose Monitors (CGM) were added to the list of covered medical devices under the Extended Health Care coverage for policies 50832. CGM receivers, transmitters and sensors are covered for employees, retirees and dependants with Type 1 diabetes up to a combined maximum of $4,000 per person per calendar year. A Doctor’s note with the diagnosis must be provided to Sun Life along with the claim for CGM supplies.

If you have any claims for these devices which were purchased after December 1, 2019, please submit them for reimbursement.

About the CAAT Academic Joint Insurance Committee

The CAAT Academic Joint Insurance Committee (JIC) is formed under Appendix IV of the CAAT Academic Collective Agreement. The purpose of the JIC is to facilitate communication between the College Employer Council (CEC) and OPSEU on the subject of group insurance.

Every month the JIC works to overturn decisions made by Sun Life on claim denials under the Extended Health, Dental, Long Term Disability, and Life Insurance (including Basic, Supplementary, Supplementary Spousal and Dependent) plans.

The JIC meets monthly to review claim problems and attempt to resolve them. OPSEU’s representatives, as your advocates, take an active role in JIC meetings.

Why would I want to appeal a claim that has been denied?

  • Your claim may have been improperly denied (it happens more often than you think).
  • Claims that are denied today may highlight important future bargaining demands.

How can I appeal claims for denied insured benefits?

Appeal the denial through the union members of the JIC listed below.  The JIC is comprised of OPSEU representatives and the College Council. Sun Life representatives also attend. 

Who are my JIC Union representatives?

Heather Giardine-Tuck, Co-Chair, Local 240, Mohawk College heathergiardinetuck@hotmail.com
Urszula Kosecka, Local 562, Humber College cogito727@yahoo.ca
Landyn Blais, Local 415, Algonquin College lblaisopseu415@gmail.com
Terry Poirier, Local 242Niagara College tpoir76@gmail.com
Giulia Volpe, OPSEU Benefits Counsellor gvolpe@opseu.org

How do I commence an appeal to the Joint Insurance Committee?

  • First, make certain (through phone call, email or discussion) to note your complaint with Sun Life, the College Benefit Administrator at your College, and your Local Union when you become aware of the denial of benefits by Sun Life. Sometimes submitting additional information directly to Sun Life will resolve the problem.
  • If the complaint is not satisfactorily resolved, contact one of the members of the Joint Insurance Committee so that they can advocate for you. It is essential that you provide your contact information and any written documentation about what you want to appeal, such as a copy of the denial from Sun Life and the signed CAAT Academic JIC Authorization, as well as any notes or reports from your dentist or doctor.
  • Complete the authorization and send it along with your documentation to your JIC advocate or to Giulia Volpe, Benefits Counsellor. Giulia works in the Pension and Benefits Unit at OPSEU,5757 Coopers Avenue, Mississauga, Ontario L4Z 1R9 Fax: (905) 712-3009. All information submitted to the JIC is treated as confidential and will not be disclosed to anyone outside of the insurer, your treating health providers and the committee.

All information submitted to the JIC is treated as confidential and will not be disclosed to anyone outside of the insurer, your treating health providers and the committee.

Cut off or denied short- or long-term disability?

Consider applying to the Regional Hardship Fund. If you have been cut off or denied Short-Term Disability or Long-Term Disability and find yourself in financial difficulty, the OPSEU Regional Hardship Fund may be able to assist.

This fund is for OPSEU members in good standing who are experiencing unexpected and/or temporary financial hardship. The regional hardship fund provides emergency financial assistance to eligible members based on need, duration and what is available in the current budget.

Download an application form from https://opseu.org/forms.

Prior authorization

While the Collective Agreement provides for negotiated premiums to be paid for negotiated drug coverage, the Council has the unilateral right to modify how the plan is administered. At the Joint Insurance Committee, we have been advised that effective February 1, 2020, Council has decided to add Prior Authorization to our benefit plan. This means that pre-approval will be required for approximately 200 specialty drugs out of the 14,000 drugs our plan currently covers (there is no change to the list of drugs our plan covers). Council has assured that:

Prior authorization only applies to certain specialty drugs. If you are already taking one of the prior authorization drugs, you do not need any further approval. Anyone prescribed a prior authorization drug as of Feb. 1, 2020, will go through the approval process. Turnaround time for approval is 5 business days. We have attached the communications from Council for additional information. At the JIC, we will be monitoring the impact of this change to the plan and alerting Council should there be any negative impact on our members. As always, if you have any questions or concerns, please reach out to us on the JIC.

Premium rate report

As part of your Joint Insurance Committee’s ongoing responsibilities for fiscal prudence, we annually review with Council and Sun Life the financials related to your benefits. This year, as part of our recommendations, we are happy to report a decrease in the premium rates for faculty extended health benefits. Ensuring that your benefits are fiscally sound is an annual collaborative JIC exercise to ensure that your benefits are funded responsibly.

What happens to your benefits when you continue working beyond 65?

With more members choosing to continue their careers past the age of 65 (no longer the mandatory retirement age since December 12, 2006), many are concerned about which of their benefits will continue and which may cease.

The following active employee benefits are maintained for as long as the employee is working full-time with the premium-sharing arrangements identified in the Academic Collective Agreement continuing to apply:

  • Basic Life Insurance – $25,000
  • Accidental Death and Dismemberment – $25,000
  • Extended Health Care (including Vision and Hearing Care)
  • Dental Care

After age 65, regardless of working full-time, the following benefits cease to be covered:

  • Supplementary Life Insurance – $60,000
  • Employee Pay-All Life Insurance – $40,000
  • Dependant Life Insurance
  • Long-Term Disability

Members may convert the above life insurance to an individual policy with Sun Life if they wish. They have 31 days from the date coverage ceases to do so without having to provide Sun Life with “evidence of insurability”. Your Benefits Administrator will send you the appropriate notices so that you can apply for the conversion option. Members are advised to compare the rate quoted by Sun Life with other insurance providers in order to make an informed decision which will suit their personal situations and finances.

Question corner

Q. I am a partialload instructor hired for the first time from January to April. I already have a health plan and understand Extended Health Care is mandatory. What happens when this term ends? I may or may not be hired back. Am I obligated to continue paying the premiums myself?

A. The college is required to pay 100% for your extended health care coverage (single or family), so there are no premiums to pay for this coverage by you. Although you may already have coverage under another plan, you can co-ordinate benefits between plans so that you can enhance the coverage you already have. For instance, the college’s drug plan pays 85% for drugs legally requiring a prescription, and your other plan could top it up to 100%, or vice versa. You can also enhance your paramedical coverage (massage, chiropractor, etc.). The extended health care is part of your negotiated terms of employment with no cost to you, and there is nothing to lose in signing up for it. You also have access to “optional” benefits (dental, vision, etc.) which you can choose to pay premiums for, or not.

Q. I am a partial-load employee who waived dental benefits when I first became eligible for benefits. I did not have coverage for dental anywhere else either. I would now like to participate in dental benefits, but I am being told that I can’t. Why is that?

A. If you do not take dental benefits (or other optional benefits) when you first become eligible for them, and you are not covered for those benefits elsewhere (a spouse, another workplace, etc.), you will be excluded from participating in these benefits until have you have had a six-month gap in employment at the college. If you have waived these benefits because you have coverage elsewhere, and then lose that coverage, you must join the college’s plan within 30 days of losing coverage, otherwise the same conditions apply.

The reason for this is to protect the plan from “adverse selection”. Adverse selection is when people choose not participate in coverage until they need it, and therefore don’t pay into the insurance until they need it. Adverse selection raises the costs of delivering benefits, which affects everyone.

Q. I am contemplating retirement this summer and I am wondering if my benefits will stay the same, or if they will change. I am also wondering who pays for retiree benefits?

A. The college retiree benefit plan currently offers three levels of coverage from one that is very close to your existing benefit plan to a more pared-down version. Premiums vary between the plans and are paid 100% by retirees. You can get details on the level of coverage from your Benefit Plan Administrator at your college.

We encourage people to look at retiree benefits outside of the college system to compare not just the premiums, but also the levels of coverage. Pay particularly close attention to yearly and lifetime maximums on drugs, and as this component of a health plan can save your life, as well as your life savings. Unfortunately, the Ontario Drug Benefit program for seniors does not cover many drugs, leaving you (or your drug plan) to make up the shortcomings of the plan.

Q. I am currently on LongTerm Disability (LTD). How long will I get LTD benefits for?

A. It depends. LTD benefits are payable to members who have completed a qualifying period and are still considered “totally disabled”. For the first two years of LTD benefits, totally disabled means “you can perform none of the duties relating to your regular work during for a period of up to 24 months”.

After 24 months of LTD payments under this definition, the definition changes and you must be considered “wholly and continuously prevented from engaging in ANY occupation or employment for wage or profit for which you are reasonably qualified by education, training or experience.” Wage or profit is defined as an ability to earn income which would be commensurate to your monthly LTD payment.

LTD disability payments end at age 65 regardless of whether you continue to meet the definition of total disability.

If there are questions you would like to see answered in the next “Benefits You”, please pass them along to an OPSEU JIC member!

Heather Giardine-Tuck, Co- Chair, Local 240, Mohawk College heathergiardinetuck@hotmail.com
Terry Poirier, Local 242, Niagara College tpoir76@gmail.com
Urszula Kosecka, Local 562, Humber College cogito727@yahoo.ca
Giulia Volpe, OPSEU Pension and Benefits Unit gvolpe@opseu.org
Landyn Blais, Local 415, Algonquin College lblaisopseu415@gmail.com