ABOUT YOUR PLAN

MORE INFORMATION ABOUT YOUR PLAN

Your Plan

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 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 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. For a full breakdown of benefits, go to OTIP’s secure member website once you have enrolled.

What’s included – Just remember to check your eligibility and coverage with OTIP prior to accessing services and providers.

 

  • What’s Included

    Prescription Drugs

    • Plan members receive a pay-direct benefits card, coverage for most prescription drugs, and help with dispensing fees.

    Dental Insurance

    • Basic dental for you and your family, as well periodontic/endodontic work like root canals and gum treatments, as well as some coverage for major restorative services.

    Medical Supplies and Services

    • Your plan covers any medically necessary trips in an ambulance to the nearest treating hospital / facility, as well as some coverage for supplies like glucometers, hearing aids, orthopaedic supports and private duty nursing.

    Paramedical

    • Paramedical is a valued benefit and the plan has included some provisions. Coverage includes support for massage therapy treatments, some counselling, naturopath services and help from other professionals.

    Hospital

    • Your plan will cover a semi-private hospital room in OHIP-funded facilities.

    Vision Care

    • You have some coverage for glasses, contact lenses and laser eye surgery, as well as eye exams every two benefit years.

    Travel Medical

    • Your plan can help you if you have a medical emergency while travelling. Eligible plan members who are Canadian residents can learn more about travel coverage by clicking here.

    Life and Accident Insurance

    • The plan includes basic life and access to optional insurance based on salary and age, as well as partial coverage for accidental death and dismemberment insurance.

    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.

  • New member? How to enrol

    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.

     

    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 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.

  • Submitting a claim

    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.

  • Appealing a Claim

    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.

    Click here for more information.

  • ETFO ELHT Anti-fraud Policy

    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:

    • Embezzlement
    • Misappropriation, misapplication, destruction, removal or concealment of property
    • Alteration or falsification of paper or electronic documents, including the inappropriate destruction of paper or electronic documents
    • False claims and/or misrepresentation of facts
    • Theft of an asset including, but not limited to, money, tangible property, or intellectual property
    • Bribery, kickbacks or rebates

    REPORTING

    Beneficiary/Health Service Professional Fraud

    1. The Carrier has the primary responsibility for all investigations involving Plan Member or health service professional fraud, abuse or improper conduct. The Carrier shall contact the Third Party Administrator (TPA) who shall contact the Benefits Coordinator with suspected cases of fraud, abuse or improper conduct.
    2. Cases shall be presented anonymously to the Benefits Operations Committee for review and recommendation to the Board.
    3. The Board shall vote on the recommendations presented by the Benefits Operations Committee.
    4. The Benefits Coordinator shall communicate the decision of the Board to the TPA who shall inform the Carrier.

     

    Employee, Contractor, Board Member, Stakeholder Fraud

    1. Suspicion of fraud, abuse or improper conduct shall be reported to the Benefits Coordinator and the Chair of the Board who shall coordinate the investigation.
    2. Should it not be possible to report suspicion Fraud, Abuse or improper conduct to either the Benefits Coordinator and/or the Chair of the Board, reports should be made to 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.
    3. If the investigation substantiates that fraud, abuse or improper conduct has occurred, the Benefits Coordinator and Chair of the Board will issue the appropriate reports and recommendations to the Board. Legal counsel or audit services shall be used where deemed necessary. Auditing reports shall be presented to the Board by the Audit, Investment and Risk (AIR) Committee.

    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:

    1. Suspension of, or permanent removal of access to online claims
    2. Referral of all future claims to Carrier Risk Management for monitoring and verification
    3. Pursue overpayment through Carrier
    4. Filing a statement of facts with law enforcement
    5. Civil litigation

     

    Employee, Contractor, Board Member, Stakeholder Fraud

    Actions recommended by the Benefits Coordinator and/or Chair for decision by the Board may include but are not limited to:

    1. Disciplinary action up to and including termination
    2. Filing a statement of facts with law enforcement
    3. Civil litigation
    4. Removal from the ELHT Board of Trustees
    5. Termination of Services Contract

    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.

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