Eligibility

  • Is the ELHT plan mandatory for 1.0 Teachers, DECEs, PSPs, ESPs and eligible 1.0 Long Term Occasional Teachers?

    Coverage under the ETFO Benefits Plan is mandatory for permanent teachers, DECEs, PSPs and ESPs, and eligible long-term occasional teachers working in a 1.0 full-time equivalent position (FTE).

    Mandatory coverage includes basic life, health and dental, and AD&D. However, members with spousal coverage may waive the health and dental coverage. Eligible members on a non-statutory approved leave may elect to continue to participate in the benefits on a 100% paid basis (i.e. member pays 100% of the premium cost).

    Eligible part-time members may elect to participate in the benefits plan on a pro-rated premium basis (i.e. 0.5 members pay 50% of the monthly premium).

  • I am an ETFO member and have been laid off by my Board. If I am on my Board's recall list, am I still eligible to participate in the ETFO ELHT Benefits Plan?

    Members on a Board Recall List 
    Eligible ETFO members who have been laid off and are on their board’s recall list are eligible to participate in the ETFO ELHT benefits plan, if they were enroled in the plan immediately preceding their lay off.  They are eligible for up to 24 consecutive months while on the recall list and would be required to pay 100% of the monthly premiums to participate in benefits.  Alternately, plan members on the recall list can opt out of benefits for the period of the recall, but would only be permitted to opt back in when they return to a permanent position or to an eligible LTO. **

    Once the eligible member begins on the recall list, OTIP will send information regarding arranging premium deductions.  For example, an eligible ETFO member who is laid off effective September 1st will receive correspondence within 2-3 weeks of that date.

    For information regarding the approximate cost of monthly premiums, members can view here:  PDF | Word

    ** Members who opt out of the benefits plan while on the recall list can only opt back within 31 days of returning to a permanent assignment or eligible LTO.

    Link to more information about layoffs and benefits.

  • How do I add an eligible dependant (i.e. spouse/partner, eligible child) to my benefits plan?

    Eligible members may change from single to family benefits and/or add an eligible partner or child to the health and dental plan without evidence of medical insurability if they experience a life event/change (e.g. birth/adoption of a child, marriage/common law qualification, loss of spousal benefits) or have an increase or decrease in FTE (e.g. increase from 0.5 to 0.7 or 1.0; decrease from 0.9 to 0.6; etc.)  if completed within 31 days of the event and while the member is actively at work.

    For more information about life/events and how to add an eligible dependant (i.e. spouse, eligible child), click here.

  • I am a new eligible member (e.g. newly hired permanent Teacher, DECE, PSP, ESP or eligible LTO Teacher). How will I know how to enroll in the plan?

    Newly eligible members (e.g. a newly hired permanent Teacher, DECE, PSP, ESP or an LTO Teacher in an eligible 90+ day LTO) will receive an email invitation to enroll I the ETFO ELHT benefits plan, usually within 2 – 4 weeks of their eligibility date once the board has provided OTIP with all required data. For example, an eligible member whose eligible assignment start date is the first day of the school year should receive the their email to their board email address before the end of September. If you are eligible and have not received your email invite within four weeks, please contact OTIP at 1-866-783-6847 to inquire.

    Eligible members have 31 days from the date the enrolment email invite is received to complete the required enrolment on OTIP’s secure member portal. Eligible members who do not complete their enrolment within that time will be considered a “late applicant” and will be required to provide medical evidence of insurability to enrol. Enrolment by late entrants is subject to approval of medical evidence and can result in limits to coverage and/or denial of coverage.

  • If I am not in an eligible full-time (i.e. 1.0 FTE) assignment or if I am on an unpaid leave (e.g. deferred or x/y leave, personal leave, extended parental leave, unpaid medical leave), what are the costs of monthly pro-rated premiums?

    As members log into OTIP’s secure website to review and validate their coverage information, any required member contributions will also be displayed. Members can also view the supplemental life, extended health and dental premiums here: PDF | Word.

    Eligible Part-time Members
    Members who are in eligible part-time assignments pay pro-rated premium (e.g. 0.5 FTE would pay 50% of monthly premiums; 0.7 would pay 30% of monthly premiums) if they wish to participate in benefits. Alternately, plan members who are working in part-time assignments can opt out of benefits for the period of the leave, and opt back in within 31 days of a change in FTE (i.e. increase or decrease) or experience a life event (e.g. marriage/common law qualification, birth/adoption, loss of spousal benefits).

    Members on Unpaid Leaves
    Members on an unpaid leave (including deferred or x/y leaves, personal unpaid leaves, unpaid extended parental leaves, unpaid medical leaves) would be required to pay 100% of the monthly premiums to participate in benefits.  Alternately, plan members on an unpaid leave can opt out of benefits for the period of the leave, and opt back in when they return to work.**

    Members on Statutory Leaves
    Members on an eligible statutory leave, including statutory maternity, statutory parental leaves and other statutory ESA leaves continue to have access to funded benefits on the same basis as when they are actively at work.  Part-time members who are on a statutory leave continue to have premiums funded on a pro-rated basis (e.g. 0.5 FTE on a statutory maternity/parental leave would continue to pay 50%) if they wish to participate in benefits during the statutory portion of their leave. Alternately, part-time plan members can opt out of benefits for the period of the leave, and opt back in when they return to work.**

    ** Members who opt out of the benefits plan while on leave can only opt back within 31 days of returning to their paid assignment.

  • Is there a deadline or time limit for changing my benefits from single to family or for adding a dependant partner or child to my ETFO ELHT benefits plan?

    Eligible members may change from single to family benefits and/or add an eligible partner or child to the health and dental plan without evidence of medical insurability if they experience a life event/change (e.g. birth/adoption of a child, marriage/common law qualification, loss of spousal benefits) or with an an increase or decrease in FTE (e.g. increase from 0.5 to 0.7 or 1.0; decrease from 0.9 to 0.6; etc.)  if completed within 31 days of the event and while the member is actively at work. An eligible member who has opted out of the health and dental plan may also opt back into within 31 days of a life event/change (e.g. FTE increase or decrease, birth/adoption of a child, marriage/common law qualification, loss of spousal benefits) and while the member is actively at work. For more information about life/events and how to add an eligible dependant (i.e. spouse, eligible child), click here.

    For further clarification, please note that:

    • If a plan member opted out of the benefits plan while on leave, they cannot opt back into the plan while on their leave.
    • If a plan member misses the 31 day window to opt into the plan, they will be considered a late entrant and will be required to provide medical evidence to the insurer to apply.  The application may be approved, denied, and/or subject to coverage limitations.
    • If a plan member misses the 31 day window to add an eligible dependant, that dependant will be considered a late entrant and the member will be required to provide medical evidence to the insurer to add that dependant(s).  The application may be denied and/or subject to coverage limitations.  For example, a plan member is married on July 15th and wishes to add their new spouse.  The member must add the spouse no later than August 16th to avoid medical evidence of insurability.  After August 16th, the plan member would be required to provide medical evidence for their new spouse and the spouse could be approved, denied, and/or have coverage limitations for a period of time.
  • What about members who were on leave and unreachable during transition into the ETFO Benefits Plan?

    OTIP and ETFO are making every effort to ensure all eligible members receive sufficient notice to enrol in the ETFO Benefits Plan, including providing enrolment information via multiple communication channels such as mail and email.

  • Can temporary or occasional DECE/ESP/PSP members pay in the plan?

    Temporary or Occasional DECE/ESP/PSP members, including those in long-term occasional positions, are not eligible to participate in the ETFO ELHT provincial benefits plan.

    OTIP is working on a restructuring of the Occasional Education Employee Plan to provide educational workers options for individually elected benefit coverage. Information will be available on OTIP’s website once they are able to restructure that plan.

  • Do I need to provide evidence of insurability to be eligible for the ETFO ELHT Benefits Plan?

    At the transition, all eligible ETFO members and their eligible dependants were invited to enrol in the ETFO Benefits Plan without medical evidence of insurability provided the enrolment process was completed within 31 days from their transition start date. For example, ETFO members who transitioned were required to complete their enrolment online within 31 days of their start date (e.g. November 1, 2016, February 1, 2017, April 1, 2017, June 1, 2017 or August 1, 2017)

    Eligible members may have future opportunities to make changes to basic components of the plan (health and dental) without evidence of medical insurability if they experience a life event/change (e.g. increase in FTE, birth/adoption of a child, marriage/common law qualification, loss of spousal benefits) if completed within 31 days of the event and while the member is actively at work. For more information about life/events, click here.

    Newly hired members will receive an invitation to enroll in the ETFO ELHT benefits plan within 2 – 4 weeks of their eligibility date. Those members have 31 days to opt into health, dental, and basic life and AD&D coverage without medical evidence of insurability. After 31 days, medical evidence is required and can result in limits to coverage and/or denial of coverage. Optional life and AD&D coverage (e.g. Supplemental, Optional, Optional Spousal/Child) require evidence of insurability.

  • How does eligibility work for Long Term Occasional (LTO) teachers?

    The ETFO provincial benefits plan provides coverage for LTO teachers based on the following eligibility criteria:

    • Assignment must be 90-consecutive calendar days or longer (except where there is currently a shorter eligibility rule in the collective agreement – e.g. currently 60-consecutive calendar days, the LTO teacher would be eligible);
    • Enrolment in the benefits plan is mandatory for 1.0 teacher in an assignment for 90 consecutive days or longer;
    • Benefits coverage will begin on the first day of a known assignment and coverage will cease upon termination of the assignment; and
    • Must be one continuous assignment of at least 90 consecutive calendar days (e.g. a 45-day assignment followed by another 45-day assignment will not constitute eligibility).

    Members in eligible assignments where the FTE is less than 1.0 and who voluntarily opt into health and/or dental benefits will be required to pay health and dental premiums on a pro-rated basis (e.g. .06 FTE would be required to pay 40% of the monthly premium for health and dental).

    LTO eligibility rules may be combined with contract eligibility rules – for example, where a 0.5 contract member also has a 0.5 LTO assignment of 90 consecutive days or longer, the member may combine eligibility and premium share to receive full benefits coverage with no member contribution for the duration of the LTO assignment.

    Following the completion of the LTO assignment, should the member voluntarily opt into health and/or dental benefits the member will be responsible for paying 50% of the premiums for health and dental as required by the eligibility rules for part-time permanent employees.

Medical and Treatment Coverage

  • Where can I view the ETFO ELHT benefits booklet?

    For a benefits-at-a-glance summary of the benefits, please click here.

    Once you are enrolled in the benefits plan, you can log into OTIP’s secure member website at otip.com to access the ETFO ELHT Benefits Booklet.  Once you have logged into your secure member profile, click on “My Claims”.  On the next screen, click on the “My benefits” tab along the top (next to the “Home” tab) and you can then click on “View benefits booklet”.  Specific questions about coverage can be directed to OTIP at 1-866-783-6847.

    * Please note that deductibles and other reasonable and customary (R&C) limits may apply.  It is always recommended that you check your eligibility and coverage with OTIP prior to accessing services and providers, particularly for higher cost benefits.

     

  • Do members receive a drug card?

    Yes, all eligible ETFO Benefits Plan members will receive a new pay-direct benefits card. Additional benefits cards can be printed online from your profile on the OTIP portal:

    1. Log in to the portal
    2. Select “My Claims”
    3. Select “my profile” along the top menu bar
    4. Select “my benefits card”
    5. Click on the sample card
    6. Print
  • Are all eligible paramedical claims fully covered under this plan?

    Eligible paramedical claims are covered up to reasonable and customary limits. Reasonable and customary (R&C) refers to the maximum allowable amount that an insurer will reimburse on a service or item. This is an approach by insurers to limit allowable costs for some services within a plan without providing a fixed hard cap. For example, if the reasonable and customary cost for a service is $90 per visit or per hour and the provider bills $120 per visit or per hour, only $90 will be reimbursed.  A listing of reasonable and customary limits for paramedical services can be found in the ‘My Claims’ section of your member secure area of the OTIP website at www.otip.com. A list of eligible paramedical services/providers (e.g. physiotherapy, registered massage therapist, psychologists, etc.) is available in the benefits booklet found in the secure OTIP portal.

  • Are my diabetic supplies covered?

    Largely, diabetic supplies and equipment which were considered under a prior plan will continue to be considered under the new Plan. Some supplies require a doctor’s recommendation. During the transition period, if a member contacts OTIP, a request will be made to transfer medical information across from the prior plan, and eligible claims will be paid.

  • Do I have to provide a doctor’s note for massage therapy?

    A doctors referral for message is required once every 12 months. For massage therapy claims submitted online, members will be required to check a box stating they have obtained a medical doctor’s referral for massage therapy before they submit a claim and are required to keep their doctor’s note in their personal files. All insurance claims will be subject to audit as determined by Manulife.

  • I am worried my expensive medications will not be covered. Will prior approved exceptions for a specialized prescription drug be transitioned into this plan?

    Most drugs that are not ‘over the counter’ are covered under the Plan, although there are some exceptions. Some eligible drugs require completion of a prior authorization form by a physician to determine if the drug will be covered. During the transition period, OTIP will accept previous proof of approval of specialized drugs. This proof can include a receipt showing that the specialty drug was covered under the previous plan.

    Proof of approval from the prior carrier must be received within 90 days from the transition date.

    Newly prescribed drugs that require prior authorizations will require the appropriate forms to be completed by a physician to determine if the drug will be covered, as will prior authorization drugs used by a newly eligible member of the plan (e.g. new hire).

  • What if I cannot take a generic form of a particular drug for medical reasons?

    The Plan also has a mandatory generic requirement. However, if a member or their dependant cannot take a generic drug for medical reasons (e.g. allergy to a filler in the generic drug; experience side-effects), members are able to appeal using a one-page medical form to be completed by their treating physician and submitted to OTIP for review. Please click here to download the form.

Change in Status

Transitioning to the ELHT

Enrolment and Changes

ETFO Employee Life and Health Trust (ELHT). All Rights Reserved | Privacy and Terms of Use