Your ETFO ELHT Benefits Plan takes care of what’s important to you – your health and your family. It provides you with valuable coverage when you need it.
It’s the result of looking at the needs of all our teachers and educators across Ontario, learning what benefits matter the most, and reviewing all local benefit plans to design one that fits best for all of us.
The benefits? Everyone has the same benefits across Ontario so it’s fair and equitable. And there’s no waiting period for new eligible members. The benefit year starts September 1 and ends August 31. Members can make eligible claims during the benefits year for the period of time that they are an eligible plan member.
You should know your plan is administered by OTIP, a not-for-profit organization dedicated to you – Ontario education workers, created and governed by ETFO and Ontario’s three other education affiliates. OTIP will support you every step of the way – when you enrol, submit a claim and when you have a question.
Here’s a snapshot of the benefits you receive as an eligible ETFO member. Once you are enrolled in the benefits plan, log into OTIP’s secure member website to download the full benefits booklet. For a benefits-at-a-glance summary of the benefits, please click here.
What’s included in the plan – Just remember to check your eligibility and coverage with OTIP prior to accessing services and providers. It is always recommended that plan members seek a predetermination or estimate approval prior to undergoing new services and/or expensive services or purchasing expensive devices (e.g. major dental, orthodontics, custom-made items including orthopedic shoes, orthotics, braces, etc.) or to confirm whether it is eligible for reimbursement and if so, at what level.
Prescription Drugs
Dental Insurance
Medical Supplies and Services
Paramedical
Hospital
Vision Care
Travel Medical
Life and Accident Insurance
Important Note: Reasonable and customary limits (R&C) and other limits apply to most services, supplies, and equipment. For example, It is always recommended that plan members confirm coverage limits prior to beginning treatment and/or purchasing supplies and equipment.
If you are eligible for the plan, you will receive an email from OTIP to your school board email inviting you to enrol in the benefits plan at www.otip.com/enrol. The email will provide detailed registration instructions including your OTIP identification number and instructions on how to set up your password. You will be guided through the online benefits enrolment process.
It is important you complete your enrolment within 31 days and to ensure your information is accurate and complete. During the enrolment process, you will be informed of any costs associated with your coverage selections. For example, plan members who are working in an eligible part-time assignment or who are on an unpaid leave (e.g. unpaid medical leave, x/y leave, partial leave, extended parental leave, personal leave, etc.) who wish to maintain health and dental benefits are required to pay pro-rated monthly premiums based on the portion of time they are not actively at work. (e.g. 100% leave would require 100% of the monthly premium; 0.5 FTE active assignment would require 50% of the monthly premium).
Remember – if your personal information, including your name, address and contact information is incorrect, you must contact your board to correct it.
Your Benefits Card
All eligible plan members enroled with extended health and dental coverage will receive a pay-direct benefits card in the mail, including important information on how to submit claims. You can also print out benefits cards from the My Claims section of OTIP’s secure member website once you have completed your enrolment.
If you did not receive your welcome email, please contact Benefits Services at 1-866-783-6847.
Members can submit most claims online through OTIP’s secure member website or by mailing in a claims form and supporting documents. For a copy of the form, or if you need more information about submitting online claims, log into the OTIP member website at www.otip.com or go to http://www.otip.com/forms to download the form.
Standard Appeal
The ETFO ELHT has worked closely with the Ontario Teachers Insurance Plan (OTIP), the plan administrator, to design a made for ETFO ELHT benefits plan. The ETFO ELHT Benefits Plan design sets out provisions and coverage limits for life, health and dental benefits. OTIP and the insurance carrier will adjudicate claims within the established limits set out in the plan design.
There may be occasions when a claim is partially or wholly denied and a plan member may be unclear, or may disagree, with the reasons why the claim was denied. In this case, you can appeal a claim denial by following the process below.
BACKGROUND
The ETFO ELHT Board of Trustees (the Board) are committed to protecting the ETFO ELHT’s (the Trust’s) reputation, revenue and assets from any attempts of fraud, abuse, or other improper conduct, by employees, Board members, stakeholders, health service professionals, contractors or ETFO ELHT Plan Members (Plan Members).
OVERVIEW
This document sets out the policy and procedures of the Board with respect to fraud, abuse and other improper conduct, together with the steps that might be taken where any of these practices are suspected, reported or discovered. The term “Fraud” as used in this Policy refers to any intentional act committed to secure unfair or unlawful gain including, but not limited to:
REPORTING
| It is the responsibility of every employee, Board member, and/ or agent of the Board to take all reasonable steps to report suspected instances of fraud, abuse or improper conduct committed by or against the Trust, whether by Trust employees, Plan Members, stakeholders, health service professionals or contractors.
If reporting suspected fraud, abuse or improper conduct to the appropriate personnel, as outlined in the Process below, is not possible for some reason, or if reporting suspicion may/does not resolve the matter, employees or agents of the Board should promptly contact the ETFO ELHT Legal Counsel. ETFO ELHT Legal Counsel shall request a meeting with the Board, excluding any Board member suspected of Fraud. The Board shall determine and instruct Legal Counsel on next steps. |
Beneficiary/Health Service Professional Fraud
Employee, Contractor, Board Member, Stakeholder Fraud
ACTION
Plan Member/Health Service Professional Fraud
Actions recommended by the Benefits Operations Committee for decision by the Board may include but are not limited to:
Employee, Contractor, Board Member, Stakeholder Fraud
Actions recommended by the Executive Director and/or Chair for decision by the Board may include but are not limited to:
If investigation results in a recommendation to discipline or terminate an individual, the recommendation will be reviewed by legal counsel before such action is taken.
CONFIDENTIALITY AND NON-RETALIATION
Every reasonable effort will be made to ensure the confidentiality of the reported fraud, abuse and improper conduct concern and the identity of those providing information. Investigation results will not be disclosed with anyone other than those who have a legitimate need to know.
The Board will not tolerate action against any individual for reporting, in good faith, known or suspected fraud, abuse or other improper conduct.