MAJOR MEDICAL PLAN
Devices Programme Private Duty Registered Nurse Vision Care Out of Province Coverage
The Major Medical Plan is a non-taxable benefit fully paid for by the University for all eligible full-time and part-time (half-time or greater) teaching staff and librarians. Items delisted by OHIP or changed by providers which normally were covered by OHIP are not automatically covered by the University's Plan. Participation in this programme is mandatory and coverage is immediate for all active members on or after January 1, 1990. Eligible members must choose to cover family members. Eligible family members include your spouse and your dependents, unmarried children under age 21 (under age 25 if continuously enrolled as full-time students). Your family members must be enrolled to be eligible for coverage. Please contact HR to obtain a Positive Enrolment Form used to enroll your spouse and dependants or to make necessary changes.
Coverage is continued for a Member entitled to an immediate unreduced pension from the Plan or for those who receive a reduced pension immediately on their leaving the University. The coverage provided under the Out-of-Province Emergency is reduced at retirement and those travelling beyond their retirement date should purchase out-of-province coverage. Employees hired on or after July 1, 2006 must have a minimum of 10 years of employment service at retirement to be eligible for post-retirement benefits.
Benefits are available for medically necessary services and procedures not normally covered by OHIP. These include prescription drugs (dispensing fees paid to the pharmacist are limited to $6.50) and semi-private accommodation to a limit of $110 per day in an approved hospital [If an individual is charged beyond the $110 cap, a reimbursement scheme is in place to ensure that the total charges for any particular family cannot exceed $300 per year.] plus $10 per day towards the additional cost of a private room. In addition, private duty nursing services, care in a convalescent home, accidental dentistry, and certain artificial appliances are benefits under this Plan. Limitations apply to these coverages.
Subject to limitations, treatment by psychologists, physiotherapists, chiropractors, podiatrists, chiropodists, osteopaths, naturopaths and massage therapists is also covered to a maximum of $300 per practitioner per person per benefit year. Licenced speech therapists are covered to a maximum of $200 per person per benefit year.
DEVICES PROGRAMME
Effective July 1,1998 Benefit Guidelines were introduced to provide improved and consistent coverage for the many devices currently in use, some of which were covered and some of which were not, and to allow new devices to be covered.Devices are categorized into six groups (for further information, see the Major Medical Brochure available from HR). In some cases, deductibles apply; co-insurance and limits on some devices also apply.
- All benefits payable under the Provincial Assistive Devices programme, other group programmes or community organizations should be claimed first. These programmes establish protocols and normal prescribing and payment guidelines upon which our Plan builds.
- Expenses will be categorized by type and the amount of benefits payable will be determined according to this expense type.
- Equipment must be prescribed by a physician (or other licensed professional as appropriate) for active medical conditions and must be generally accepted as standard medical practice. The Plan is intended to reimburse individuals for devices purchased that are considered reasonable and customary services or expenses in the treatment of the illness or injury.
- Devices necessary only for sport, comfort, convenience or recreation are not covered.
- The Plan is limited to the purchase of one device for the intended purpose in any year and is not generally liable for lost or damaged devices, nor for the repair and maintenance of such devices unless otherwise noted. Devices may be replaced when the normal lifetime of such devices has expired.
- All amounts eligible under the Plan are based on expenses beyond those payments made from other sources, unless otherwise noted.
McMaster's Major Medical Plan does not necessarily cover all medical services which are not covered by OHIP, nor does it automatically cover services no longer provided by OHIP.
OUT OF HOSPITAL SERVICES OF PRIVATE DUTY REGISTERED NURSE OR REGISTERED TRAINED ATTENDANT
Teaching Staff and Librarians, active and retired, and spouses or dependents are eligible for out of hospital services of a private duty registered nurse or a registered trained attendant, other than a close relative, in the amount of 40% of the first $25,000 (maximum $10,000) of eligible expenses and where expenses in any one case exceed $25,000, 80% of the next $25,000 (maximum $20,000) of eligible expenses. Each year after a claim has been paid, one-half of the amount utilized is reinstated. Hence, after two years with no claims, the entitlement is returned to the full coverage, or pre-claim limit.
VISION CARE
The Plan pays teaching staff, librarians, and their dependents up to $250 towards the purchase of contact lenses or lenses and frames for eyeglasses, on a rolling 24-month basis. The 24 months are counted from the date of purchase. Effective July 1, 2007 employees ONLY will receive up to $100 every two years for an eye examination.
OUT-OF-PROVINCE COVERAGE
Reimbursement for medical services received outside the province is also provided. Such reimbursement is limited to the payment of expenses beyond those covered by OHIP up to the reasonable and customary charges for treatment of an illness of the same nature and gravity in the location where treatment is provided.Out-of-province medically necessary services include all emergency services plus certain Maintenance and Preventative Services. Maintenance Services would include the care of someone whose condition such as diabetes or high blood pressure has been diagnosed and is undergoing regular treatment before leaving the country. Preventative Services are those which promote the prevention of medical conditions through regular checkups which may include such services as pre-school immunization and regular medical checkups for children or regular care during a normal pregnancy and delivery.
Claims for non-emergency services are processed through Sun Life. This coverage does not replace OHIP and claims should be processed through OHIP before being submitted to the University's Plan. A procedure to assist you with such claims can be obtained through your Area Office.
Teaching staff and Librarians are covered under the Blue Cross Deluxe Option "Health Plan While Outside Canada" for emergency medical expenses up to a lifetime maximum of $1,000,000 for any one trip up to 120 days. In the event of a medical emergency, the plan member should contact the Medical Alarm Centre indicated on the Blue Cross Card. Claims in excess of $200 will be coordinated with OHIP through Blue Cross. The employee may be required to pay for expenses less than $200 and submit to Blue Cross for reimbursement. A procedure to assist you with such claims can be obtained through HR. Out-of-province medical coverage continues until December 1st of the calendar year in which the individual reaches age 69. After that date, active employees will be eligible for the retiree out-of-country emergency travel benefit (see below).
For any trip which is for periods beyond 120 days, an application must be sent to HR for extended coverage. This coverage is provided only in those situations where the employee is travelling on University business. A $50 processing fee is charged; the University will pay the premiums. Continued coverage under these programmes while travelling is dependent on having OHIP or equivalent coverage.
At retirement, members in the Major Medical Plan are provided with out-of-province emergency coverage with a $10,000 limit per claimant's lifetime. This policy does not include reimbursement for Maintenance and Preventative Services while out of the province. Only emergency services will be considered and expenses will have to be paid for by the member and submitted to OHIP and then to Sun Life for consideration. It is recommended that all retirees purchase emergency out-of-province coverage when they are travelling outside the province.
This statement does not fully describe the Major Medical Plan. Details of the Plan are found in the laws and legal documents on which the Plan is based. The information herein is subject to these legal documents which will govern in case of difference or error.
back to top
MUFA - pdk
January 2011