How can a person claim a balance owing on a payment made by a spouse’s insurer?

This would only apply to employees whose spouse has family coverage under their own plan.  First of all, when enrolling a member who already is covered by their spouse’s plan, please ensure that coordination of benefits are set up.  If the employee has elected to also have family coverage, he/she can submit the unpaid amount of their spouse’s claim and have up to the balance paid for any eligible expense.  A copy of the Explanation of benefits from the primary carrier should be submitted.

My spouse and I are both covered under different insurance companies; who is the primary carrier for my dependant’s claims?

If an employee with coordination of benefits with their spouse’s plan has dependent children and the claims are for one of the children, the employee would submit the claim under the person with the earlier birth date in the year.

Are post-secondary students here or abroad covered under a group plan?

Yes, provided services are incurred in the home province.  Only Emergency Services received out of province/country are eligible provided that travel dates do not exceed 60 or 90 days (depending on your group insurance contract).  Routine ongoing medical treatment incurred outside the country is not eligible.

What additional information is required when submitting claims for eligible over-age dependent who is attending school?

A copy of the student card or class enrollment (showing dates) must be submitted along with the regular claim.

Can a foster child be insured under my group plan as a dependent?

A ward or foster child is only eligible for coverage if he or she is deemed a dependent under the Income Tax Act.

Can Grandparents who are living with the employee be covered?

Unfortunately, seniors cannot be covered under the group benefit plan.  Their prescriptions are covered under the Alberta Government Seniors plan.  For more information on the Alberta Seniors plan and what they offer, please see website link. http://www.servicealberta.gov.ab.ca/cps

When do benefits stop after termination of employment?

The benefits stop at midnight on the day the employment is terminated.  However, claims incurred prior to termination date may be submitted to the claims department for a period of up to 3 months after the termination date. However, premium for the month will be charged.

Alberta’s new pharmaceutical strategy which promises lowered private drug coverage expenses, is something that could be used to an employers advantage.  In “Generic Drug Re-Pricing: Your Savings Checklist,”author Tim Clarke suggests that employers are taking a “wait and see” position instead of being proactive.  Clarke asserts that “with the right strategies, the combination of generic pricing changes and the expiry of a number of high profile drug patents has the potential to result in almost zero drug inflation for 2011 and 2012. However, without specific plan elements in place, doing nothing—even temporarily—prevents employers from taking full advantage of the changes.”  Some of these strategies include introducing a drug card, using and promoting generic formularies and adding dispensing fee caps are some of Clarke’s strategies for keeping costs under control.

See Clarke’s full article with his recommendations at:

http://www.benefitscanada.com/benefit/health/article.jsp?content=20100715_161506_8240&page=1

From the Vision 2020: The Future of Health Care in Alberta PHASE ONE,

“Alberta is a leader in health care. Our health system is staffed and led by dedicated and outstanding health providers and professionals. We provide leading edge treatments and technologies and have become a national and international leader in health research. Yet there are increasing challenges and pressures on the system that must be addressed.
Health-care facilities are not used equitably. Some facilities are operating at their capacity, while others are underused. Today in Alberta, the 10 largest hospitals in the province have an average occupancy of more than 90 per cent. The vast majority of long-term care facilities have greater than 96 per cent occupancy. However, more than half of the hospitals in Alberta with fewer than 20 beds have occupancy rates below 75 per cent, and almost 20 per cent of these have occupancy rates below 50 per cent. And, almost 50 per cent of Alberta’s hospitals with fewer than 20 beds are within 50 kilometres of another hospital.
Access to some services takes too long. Sometimes patients are not being cared for in the right setting, resulting in increased waits for needed services. Too many emergent patients are using emergency departments for health concerns that could be handled by a primary care practitioner, and too many continuing care patients are being cared for in hospitals. This backs up admissions throughout the hospital and delays emergency room admissions and hospital services for people needing scheduled surgical procedures.
There are critical shortages of health service providers. As just one example, Alberta currently has a shortage of more than 1,500 nurses. By 2020, if care patterns do not change and training is not expanded, the province may be short by more than 6,000 nurses. Adding to the shortage is the fact that only 40 per cent of Alberta’s registered nurses work full-time, the lowest rate in the country and well below the Canadian average of 56 per cent. Alberta also has a growing shortage of allied health care providers, including pharmacists, physical therapists, medical technologists, and especially health-care aides.
Our population is growing, rapidly aging and facing a significant burden of chronic disease. Alberta’s population is predicted to grow by another half million people by the year 2020. Between 2007 and 2020, forecasts show the demand for hospital beds in Alberta will grow by 32 per cent, the demand for long-term care beds will climb by 52 per cent, and the demand for primary care physicians and nurses will rise 40 per cent. The high prevalence of chronic disease and cancer will drive a disproportionate share of health-care costs.”

See more at: http://www.health.alberta.ca/documents/Vision-2020-Phase-1-2008.pdf

Check out our bulletins section to see September’s bulletin. Subscribe by posting here!

One must be cautious when purchasing an Individual Health & Dental plan because many insurers do not cover pre-existing conditions. If you are taking a regular prescription you will want to make sure it will be covered.

You can call the customer service number and provide drug identification numbers to receive approval.

If you are part of a company we can provide a free employee benefits quote. Please contact us at sean.murray@beneco.ca.

Like other government programs such as Alberta Health Care the Alberta Senior Program is the first payer of any health or dental expense. When you become a participant of the Alberta Senior’s program you will receive an Alberta Blue Cross card to use when you are accessing health and dental services. Your provider will bill directly to the Seniors Program for the costs for services received subject to the limitations under the Alberta Seniors program. Any amounts not paid by the Alberta Seniors Program will be considered for reimbursement under the university plans. The University plans will pay any remaining amounts up to our plan maximums and subject to limitations. To process a claim you are required to pay for any costs in excess of the Seniors Program, then submit your expense to your carrier for reimbursement.

Retaining staff and hiring key employees is an integral part in any business strategy. The need to do this increases as competition in the business world grows. Please read the great article linked below as it speaks to this important issue.

http://www.benefitscanada.com/benefit/health_wellness/article.jsp?content=20100315_135321_5956

The Optomap Retinal Exam is a new form of eye scan which captures a 200 degree view of the retina. It is performed easily, and is encouraged for patients starting at age 3.

This new scan can provide the optometrist with the following information:
- A scan to show a healthy eye or detect disease.

-A view of the retina, giving your doctor a more detailed view than he/she can get by other means.

-The opportunity for you to view and discuss the Optomap® image of your eye with your doctor at the time of your exam.

-A permanent record for your file, which allows the doctors at the Vision Care Clinic to view your images each year to look for changes. (http://scvisioncare.com/_mgxroot/page_10769.html)

Good eyesight doesn’t necessarily mean healthy eyes. Furthermore, systemic conditions, like diabetes, high blood pressure and MS can have an effect on the eyes. Having a yearly appointment with your optometrist can catch problems before they get out of control.