Yes, the ETFO ELHT Plan has a mandatory biosimilar drug requirement. This means that if there is a biosimilar drug related to a biosimilar originator drug, the plan will reimburse the biosimilar drug. A plan member may choose to continue on the brand name drug, but the plan will not cost any of the cost of the biologic drug when there is a biosimilar drug alternative. Approved biosimilar drugs are considered by the government to be safe and effective alternatives. If a new biosimilar drug becomes available where one was not available before, plan members or their dependants will be required to switch to the biosimilar drug in order to have coverage of the drug.
In rare cases, a plan member or their dependant may have tried the biosimilar drug and is unable to tolerate it for medical reasons (e.g. experienced side-effects). In cases such as this, plan members are able to appeal using a medical form to be completed by their treating physician and submitted to OTIP for review. To access a copy of the biosimilar medical exception form, please contact OTIP at 1-866-783-6847.
Working together for sustainable benefits
The ETFO ELHT group benefits plan is the result of looking at everyone’s needs, and developing one comprehensive plan that best fits the plan membership as a whole. This means offering optimal benefits coverage to eligible plan members, and helping to protect you and your eligible dependants’ access to meaningful and sustainable benefits coverage for years to come.
Your plan is overseen by the Board of the ELHT and is administered by OTIP, a not-for-profit organization dedicated to Ontario education workers. Together, our goal is to ensure that this plan continues to meet the needs of plan members while at the same time remaining financially sustainable.
This is where you as a plan member can help. Being a smart consumer is the number one way you can assist us in achieving a balanced benefits plan that provides long-term sustainability:
If the claims and expenses exceed the benefits funding that the ELHT receives, the result could be reduction of benefits coverage and/or implementation of premium shares or coinsurance.
Yes, the ETFO ELHT has an Anti-fraud Policy (TP-025). This policy is also posted in the Our Board page of the website under Policies.
Benefits fraud and abuse can put the ETFO ELHT plan at risk and has negative consequences for the sustainability of your benefits plan. Fraud and abuse can lead to higher costs, reduced coverage, or both. While some consider benefits fraud a victimless crime, it impacts every member of the ETFO ELHT benefits plan. It also directly impacts the ability of your ETFO ELHT to provide optimum coverage amounts and maintain overall plan sustainability.
Yes, the ETFO ELHT Plan has a mandatory generic drug requirement. This means that if there is a generic drug related to a brand name originator drug, the plan will reimburse the cost of the generic drug. A plan member may choose to continue on the brand name drug, but will be required to pay the difference between the generic drug and the brand name drug. Approved generic drugs are considered by the government to be interchangeable. If a new generic drug becomes available where one was not available before, plan members or their dependants will be required to switch to the generic drug in order to have full coverage of the drug.
In rare cases, a plan member or their dependant may have tried the generic drug and is unable to tolerate it for medical reasons (e.g. allergy to a filler in the generic drug; experience side-effects). In cases such as this, plan members are able to appeal using a one-page medical form to be completed by their treating physician and submitted to OTIP. Please click here to download the form (703kB PDF). Manulife will review the form and communicate whether an exception has been granted due to medical necessity.
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.
Premiums:
If you are in an eligible 1.0 FTE position, there is no cost for health, dental, basic life and AD&D coverage while you are actively at work. If you are working in an eligible part-time FTE position, you are required to pay a pro-rated premium (e.g. 0.5 FTE would pay 50% of the monthly premium; 0.2 FTE would pay 80% of the monthly premium, etc.) if you wish to participate in benefits.
If you are an eligible part-time member (e.g. 0.2, 0.5 FTE, 0.7 FTE, etc.), please see the documents below for information about pro-rated premiums:
*Teachers/LTO Plan Premiums: PDF (262kB)| Word (168kB)
*Education Plan Premiums: PDF (266B)| Word (198kB)
*The above premium rate documents are effective September 1, 2024 and are subject to change annually at renewal.
Alternately, plan members who are working in part-time assignments may opt out of benefits. If they opt out, they can only opt back in without medical evidence of insurability within 31 days of a change in FTE (i.e. increase or decrease) or experiencing a life event (e.g. marriage/common law qualification, birth/adoption, loss of spousal benefits).
To be considered eligible to participate in the ETFO ELHT benefits plan, you must be one of the following:
Please note that daily Occasional Teachers, non-permanent Education Workers, and retired ETFO members are not eligible to participate in the ETFO ELHT Plans.
As outlined in the ELHT benefits booklet found online in the OTIP member portal, the claims submission deadline is one year from the date a specific claim was incurred as long as you are still an active permanent member. For example, an eligible claim incurred on October 19, 2021 must be submitted for reimbursement no later than October 18, 2022, as long as you are still an eligible ELHT plan member.
Plan members who have retired, resigned, or who were in an eligible LTO, have one year from the date an eligible claim was incurred OR 90 dates after their end/retirement date (whichever is earlier). For example, a plan member who retires on June 30, 2021 or ends their eligible LTO on June 30, 2021 has until September 28, 2021 (90 days after June 30, 2021) to remit eligible claims incurred between September 27, 2020 and June 30, 2021.
Just a reminder that benefits coverage always ends at 11:59 pm on the last day that you are eligible for benefits. A plan member who retires or ends an eligible LTO on March 31 has their benefits terminated at 11:59 pm on March 31. They would have until June 29 to remit eligible claims under the same rules as above.
Yes, plan members and their dependants (i.e. eligible spouse/common-law partner, eligible children) who are living in Canada must have active provincial coverage (i.e. OHIP for those living in Ontario; RAMQ in Quebec) to be eligible for the ELHT plan. A member (or their dependants) who does not have provincial coverage is excluded under the plan. If they qualify for provincial coverage at a later date, they are able to opt into the plan within 31 days of receiving the provincial coverage (i.e. receive their OHIP/RAMQ coverage). For information about eligibility and applying for OHIP coverage, please visit the Ontario government website at https://www.ontario.ca/page/apply-ohip-and-get-health-card.
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.
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:
*Teachers/LTO Plan Premiums: PDF (262kB)| Word (168kB)
*Education Plan Premiums: PDF (266B)| Word (198kB)
*The above premium rate documents are effective September 1, 2024 and are subject to change annually at renewal.
** 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.
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 for 1.0 FTE members includes basic life, health and dental, and AD&D. However, 1.0 FTE 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. plan 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; 0.2 members pay 80% of the monthly premium; etc.). If a part-time member does not opt into the plan when they are first eligible, that cannot opt in without evidence of medical insurability until they have a life event (e.g. marriage/divorce/common-law qualification, birth/adoption, etc.) or have a change in their FTE. If they have a change, they must contact OTIP within 31 days if they wish to opt in at that time.
If you are an eligible part-time member (e.g. 0.2, 0.5 FTE, 0.7 FTE, etc.), please see the documents below regarding premiums costs:
*Teachers/LTO Plan Premiums: PDF (262kB)| Word (168kB)
*Education Plan Premiums: PDF (266B)| Word (198kB)
*The above premium rate documents are effective September 1, 2024 and are subject to change annually at renewal.
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:
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.
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 eligible members will receive an invitation to enroll in the ETFO ELHT benefits plan within 3 – 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) always require evidence of insurability.
When does my ELHT plan end?
Benefits terminate at 11:59 p.m. the effective date an eligible member retires or resigns. For example, if a member retires or resigns on January 31, their benefits would terminate at 11:59 p.m. on January 31. If a member retires or resigns on June 30, their benefits would terminate at 11:59 p.m. on June 30. If a member retires or resigns on August 31, their benefits would terminate at 11:59 p.m. on August 31, etc.
For more details, please read this article.
The ETFO ELHT benefits plan provides coverage for Occasional Teachers based on the following eligibility criteria:
Part-time Pro-rated Premiums
Occasional Teachers in eligible LTO 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. 0.6 FTE would be required to pay 40% of the monthly premium for health and dental; 0.2 FTE would be required to pay 80%, etc.), retroactive to the first day of the eligible LTO assignment.
Combining Permanent and LTO Contracts
LTO eligibility rules may be combined with contract eligibility rules – for example, where a 0.5 permanent teacher also has a 0.5 LTO teaching 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 to maintain 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.
Premiums
If you are an Occasional Teacher in an eligible part-time FTE (e.g. 0.2, 0.5 FTE, 0.7 FTE, etc.) LTO assignment, please see the documents below for premium costs:
*Teachers/LTO Plan Premiums: PDF (262kB)| Word (168kB)
*The above premium rate documents are effective September 1, 2024 and are subject to change annually at renewal.
If an LTO assignment is extended to 90 consecutive calendar days or longer, the Occasional Teacher will be eligible to enrol in the Plan retroactively to the first day of their assignment. Standard premium contribution rules will apply. The extension must be of the original LTO to be eligible. For example, a 60 calendar day LTO assignment followed immediately by a new 30+ calendar day LTO assignment does not qualify as an eligible LTO.
For example, no premium contribution is required by an Occasional Teacher working in a 1.0 FTE LTO assignment of 90 consecutive calendar days or longer; an Occasional Teacher working in a 0.5 FTE LTO assignment who voluntarily opts into health and/or dental benefits will be required to pay 50% of the premium for health and dental. (0.7 FTE would pay 30%, etc.) If premium is required, it will be retroactively assessed through direct withdrawal (PAD) from the member’s bank account once they are enrolled.
Claims for eligible expenses incurred will be honoured back to the first day of the eligible LTO assignment. Therefore, members are encouraged to keep their receipts if they expect their LTO assignment may be extended.
To be eligible for ELHT benefits, an LTO assignment must be at least 90 days or longer. A new LTO assignment which is shorter than 90 days (e.g. 45 days, etc.) will not be eligible for benefits, even where it follows an eligible 90 day LTO.
If a 90-consecutive calendar day LTO assignment gets shortened unexpectedly then coverage will cease upon termination of the assignment. Members will not be required to repay any claims that were paid to them while coverage was in force. For example, an Occasional Teacher accepts an LTO assignment on October 1st and it has a known end date of May 15th which has been reported by the board to OTIP. The permanent teacher returns to their position earlier than expected on December 5th, so the LTO position ends at the end of the day on December 4th. The Occasional Teacher/LTO’s benefits would be terminated on December 4th at 11:59 p.m.
ELHT benefits coverage will cease for an Occasional Teacher when the LTO assignment ends on the last day of the school year or the last day of the eligible LTO assignment, whichever date comes first.
For Occasional Teachers who have been in LTO assignments of 90 consecutive calendar days or longer which conclude at the end of the school year, benefits coverage will cease on the last day of the school year. If the new assignment replacing the same teacher in September is known to be at least 90 consecutive calendar days or longer from the September start date, benefits will be reinstated in September when the new assignment begins.
Occasional Teachers with a 90-consecutive calendar day LTO assignment or longer who go on statutory leave (maternity, parental, ESA leave) will be eligible for participation in the ETFO ELHT plan until the end of their LTO assignment based on their FTE assignment. For example: An occasional teacher accepts an LTO from September 7 – May 15. If this occasional teacher in an eligible LTO begins a 12 or 18 month statutory pregnancy/parental leave on January 6, they would continue to have benefits until 11:59 pm on May 15. If the LTO position ends early (e.g. on March 31), the benefits would end at 11:59 pm on the earlier end date.
Occasional Teachers beginning a new 90 consecutive calendar day LTO assignment will be notified by OTIP that they are eligible to re-enrol in the ETFO ELHT Plan. The member will be covered using the same certificate number and all claims records will remain attached to that member. For example, if the member completes a September 5 – December 20 eligible LTO assignment, benefits will end at 11:59 p.m. on December 20. If a new eligible LTO assignment is accepted and lasts January 25 – May 31, the member will receive another enrolment email from OTIP and benefits will begin again January 25 using the same OTIP ID number. Yearly coverage limits will be reduced by any claims amount that were accessed during the September 5 – December 20 period of benefits. Lifetime maximum coverage (e.g. orthodontics) and 2-year benefits (e.g. vision) coverage will be reduced by any previous amounts as well.
Yes, members on all board-approved leaves of absence are eligible to participate in benefits as long as they had active benefits immediately prior to beginning their leave (e.g. deferred or x/y leave, unpaid medical leave, unpaid personal leave, approved LTD leave, WSIB leave, etc.). Members on an unpaid/deferred/x/y leave must pay 100% of their monthly health, dental, life and AD&D premiums if they wish to continue to participate in benefits. If a member opts out at the beginning of their leave, they would not be eligible to opt back into the plan until they return to active work.
Approved LTD and WSIB Leaves:
Eligible members who have maintained their benefits and are approved for LTD benefits or WSIB will be eligible to have health and dental premiums paid by the ETFO ELHT for the first 24 months of their approved LTD claim or WSIB leave (pro-rated for part-time) as long as they maintain ELHT eligibility (i.e. WSIB/LTD – permanent board employee; WSIB – teacher while in an eligible LTO).
If an eligible member is on unpaid medical leave prior to their LTD/WSIB claim being approved, they would be required to pay the cost of the monthly premiums. If the LTD/WSIB claim is approved retroactively, premiums that the member paid during that period would be refunded. For example, if a member exhausted their paid sick leave (STD) on March 31st, they would pay monthly health and dental premiums beginning April 1st if they wished to continue those benefits. If they are subsequently approved for LTD/WSIB retroactive to April 1st, they would be refunded those health and dental premiums and the 24 month period would begin April 1st.
If an eligible member continues on LTD or WSIB after the 24 month period and is still a permanent employee of the board (or in an eligible LTO for WSIB), that member may still participate in benefits by paying 100% of the cost. Please see the documents below for the cost of monthly premiums:
*Teachers/LTO Plan Premiums: PDF (262kB)| Word (168kB)
*Education Plan Premiums: PDF (266B)| Word (198kB)
*The above premium rate documents are effective September 1, 2024 and are subject to change annually at renewal.
The boards are responsible for providing Human Resources Information Systems (HRIS) data to OTIP on a bi-weekly basis that will identify when a member is eligible to enrol in the plan or if their eligibility changes. As the Plan administrator, OTIP will contact the member via email once the board has sent updated information to OTIP. Members will be required to log into their secure OTIP member portal to make their selections (e.g. opt to maintain benefits while on leave or opt out; opt into benefits when there has been an increase in FTE, etc.) Please note that work status changes can take up to 2-4 weeks to process – changes to benefits and any applicable premiums will be retroactive to the first day of the change.
When does my ELHT plan end?
Benefits terminate at 11:59 p.m. the effective date an eligible member retires or resigns. For example, if a member retires or resigns on January 31, their benefits would terminate at 11:59 p.m. on January 31. If a member retires or resigns on June 30, their benefits would terminate at 11:59 p.m. on June 30. If a member retires or resigns on August 31, their benefits would terminate at 11:59 p.m. on August 31, etc.
For more details, please read this article.
If an eligible member is on a leave of absence and has waived their benefits for the duration of their leave, they will be eligible to reinstate the same level of benefits when they actively return to work, including when they return to partial work. They will have 31 days after their return date to re-enrol in benefits without medical evidence of insurability.
Plan members in a permanent position may continue coverage for an approved unpaid leave of absence on a 100% member paid basis. During a statutory leave such as statutory pregnancy/parental leave (not an unpaid/extended parental leave), plan members will pay for health and dental benefits on an FTE pro-rated basis (e.g. if a plan member is 1.0 FTE and is on a statutory leave the ELHT will pay 100% of the premium; if a plan member is 0.5 FTE and is on a statutory leave the plan member will pay 50% of premium if the member voluntarily opts into health and/or dental benefits). During a non-statutory leave (e.g. unpaid medical leave, x/y leave, personal leave, extended parental leave, etc.) a plan member must pay 100% of the premium. If you are on a partial unpaid leave (e.g. 0.5 unpaid leave and 0.5 actively back at work you would pay 50% of the monthly premium for the 0.50 unpaid leave portion). 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.**
** Plan members who opt out of the benefits plan while on leave can ONLY opt back within 31 days of returning to their paid assignment, including when they return to partial return to active work.
Please see the documents below for information about premiums rates if you wish to maintain benefits while on an approved leave:
*Teachers/LTO Plan Premiums: PDF (262kB)| Word (168kB)
*Education Plan Premiums: PDF (266B)| Word (198kB)
*The above premium rate documents are effective September 1, 2024 and are subject to change annually at renewal.
ETFO members will be notified by OTIP when they are eligible to enrol for benefits coverage in the Plan. OTIP will send an email to the member’s board email address and the member will be required to log in to OTIP’s secure website to complete their enrolment online within 31 days of the date they first became eligible. For example, if a member was on a leave when their board transitioned into the ELHT in 2016/2017 and they had opted out of their board benefits during their leave, they would become eligible for the ELHT benefits plan once they had returned to work. Once the board notified OTIP of the change in work status (i.e. on leave to active), OTIP would send an email to the member as per above.
Your legal spouse, or person continuously living with you in the role like that of marriage partner for at least 12 months is eligible.
The ETFO ELHT defines eligible dependants as:
A step child must be living with the member to be eligible. A child who is incapacitated due to a mental or physical disability on the date they reach the age when they would otherwise cease to be an eligible dependant will continue to be eligible.
The student status of a member’s dependants will not be transferred into the new ETFO Benefits Plan. All members will be required to indicate the status of a dependant student during the enrolment process. Therefore, members are encouraged to complete their enrolment before their coverage start date to ensure that they and their dependants have the full coverage they require and to minimize any disruption to claims processing.
Under the Plan, overage dependants are covered while they are enroled full-time at a post-secondary institution until their 25th birthday. Plan members requiring proof of insurance coverage for their overage dependants should visit the OTIP member portal. Once there, select the “My Benefit” site and you will be able to print off a coverage summary. This can be provided to the post-secondary institution as proof of coverage.
Why am I issued a T4A?
A T4A slip is a statement of benefits (e.g. Basic Life, Accidental Death and Dismemberment). This is issued by OTIP, the plan administrator of your ETFO Employee Life and Health Trust Benefits Plan. If you have Basic Life and Basic Accidental Death and Dismemberment (AD&D) and are actively at work, those benefits are paid for by your Employee Life and Health Trust (ELHT). If you had this coverage at any time between January 1 – December 31, 2023, a T4A slip for these taxable benefits will be created for you if the taxable amount is more than $25. These taxable benefit amounts were calculated based on the premiums paid by your ELHT for the tax year (January to December) and should be claimed on your 2023 tax return. (Prior to 2017, these amounts would have been reported to you on your T4 slip from your school board/employer as a taxable benefit.)
NOTE: If you are a Quebec resident, we will send you a letter with information on the health and dental premiums for Revenu Quebec’s tax requirements.
Where can I access my T4A?
Beginning with this year’s T4A (2023), you will only be able to access your T4A digitally by visiting the OTIP secure member site.** This change was communicated to plan members by OTIP on February 5, 2024. You can get your current T4A slip securely online through the OTIP’s secure member site from February 28 to May 1 each year. After May 1, you can visit the Canada Revenue Agency to access your T4A slip.
**The exception is those plan members that have recently retired and those plan members on a leave – those T4As will be mailed by February 29, 2024.
To access your T4A tax slip online:
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You can also visit OTIP’s T4A FAQ on the OTIP website.
The simple answer is no. OTIP and Manulife receive an administration fee from the ELHT, and both OTIP and Manulife received a lower level of fees than normal during COVID-19 closures as their administration fee is based on paid claims (i.e. fewer claims = lower fees). The ETFO ELHT health and dental plan is not an insured plan. This means that the ELHT actually pays claims (i.e. we reimburse Manulife for each dollar that they reimburse plan members for claims) with the funding that is received. Any money not required to pay certain types of claims during the COVID-related closures stayed in the ELHT plan to use for other benefits costs now and in the future. This helped to further sustain the plan.
While there were certain decreased claims in dental, paramedicals and vision, there were other costs that were still incurred at the usual volumes/costs including drugs, which make up the largest percentage of paid claims. The ELHT lifted the limit of maintenance drug dispensing fees while drugs were only being dispensed in 30 day refills between March 23 and August 1, 2020. In addition, the ELHT was already reimbursing eligible virtual paramedical appointments, and these claims increased in 2020, and will continue to allow members to more easily access these providers. There will also be some other increased costs due to COVID-19, which may potentially include out of country claims, hospital charges, and increased life insurance claims. Claims increased during Summer 2020 as providers opened again, and have now returned or surpassed pre-COVID claims levels.
In March 2020, the Canadian Pharmacists Association made the decision regarding the 30 day limit to preserve the supply of medication during this unprecedented time. In response, your ETFO ELHT temporarily turned off the limit on the number of dispensing fees per 12-month period for maintenance medications. This is to ensure members can continue to access the medications they need, without incurring the full cost of the additional dispensing fees.
In June 2020, the Ontario Government and Pharmacists Association announced that the 30 day dispensing limit could be lifted. As a result, the 5 dispensing fee limit per 12-month period for maintenance medications were reinstated effective August 1, 2020, on a go forward basis.
Yes, the ETFO ELHT Plan has a mandatory biosimilar drug requirement. This means that if there is a biosimilar drug related to a biosimilar originator drug, the plan will reimburse the biosimilar drug. A plan member may choose to continue on the brand name drug, but the plan will not cost any of the cost of the biologic drug when there is a biosimilar drug alternative. Approved biosimilar drugs are considered by the government to be safe and effective alternatives. If a new biosimilar drug becomes available where one was not available before, plan members or their dependants will be required to switch to the biosimilar drug in order to have coverage of the drug.
In rare cases, a plan member or their dependant may have tried the biosimilar drug and is unable to tolerate it for medical reasons (e.g. experienced side-effects). In cases such as this, plan members are able to appeal using a medical form to be completed by their treating physician and submitted to OTIP for review. To access a copy of the biosimilar medical exception form, please contact OTIP at 1-866-783-6847.
For those 18 and older, the benefit plan covers up to a combined maximum of $500 per 2 plan years for:
*For example, if a plan member is reimbursed for an eye exam in the 2023-2024 benefits year, they will not be reimbursed for another eye exam until the 2025-2026 benefits year, and only if they have room left in their allowable amount for that year.
$500 is available over any two years. To determine how much you have available in a new benefits year, subtract the amount reimbursed to you last year from $500. For example:
For a full explanation of the vision coverage, please click here to read the article Understanding Your Vision Care Coverage published in a previous OTIP eNewsletter and posted in the news and resources sections of this website.
As always, if you are unsure of your available coverage, it is highly recommended that you confirm with OTIP before you incur an expense.
ETFO ELHT Benefits:
Eligible ETFO ELHT plan members have access to counselling coverage under the ETFO ELHT.
OTIP Website:
In addition, OTIP has compiled and posted a list of resources on their website to help connect plan members with other resources that may be helpful to support mental health and wellness. Whether it is access to mental health services, crisis help lines, or tools for speaking to your children about anxiety and dealing with change, we are here to support you.
OTIP has also partnered with Starling Minds – click here for more information about their free mental health and wellness programs and resources!
Plan members who are Canadian residents and are actively enrolled in the ETFO ELHT health plan do have coverage in the case of an unforeseen medical emergency while travelling outside of Canada.
Details of your travel coverage can be found in your benefits booklet (found on the OTIP website in your secure plan member portal) under the Out-of-Province/Out-of-Canada section that covers topics such as:
This coverage is for emergency medical assistance and does not include trip cancellation coverage.
Visit the travel section on OTIP’s website for tips, or contact OTIP at 1-866-783-6847.
** If you have a known medical condition, have recently seen a doctor, or are within the last four weeks of a pregnancy, it is strongly recommended that you review the information related to pre-existing conditions and medically stable definitions and contact OTIP at 1-866-783-6847 before travelling.
For a benefits-at-a-glance summary of the benefits, please click here.
Once you are enrolled in the ETFO ELHT benefits plan, you can log into OTIP’s secure member website at otip.com to access the ETFO ELHT Benefits Booklet:
Specific detailed 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. A pre-determination or estimate should be submitted prior to beginning treatment for higher cost benefits.
Yes, all eligible ETFO Benefits Plan members receive a new pay-direct benefits card when they enrol. Additional benefits cards can be printed online from your profile on the OTIP portal:
Eligible paramedical claims are listed in the benefits booklet as well as the benefits summary, and 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 most up-to-date benefits booklet found in the secure OTIP portal. If you are unsure whether a provider is eligible under the plan, please contact OTIP at 1-866-783-6847 with the provider’s credentials and/or submit a predetermination/estimate of the treatment to OTIP.
A wide range of diabetic medications, supplies and equipment are eligible for some coverage under the ELHT Benefits Plan. Please note that:
Plan members with questions about coverage for diabetes medications, supplies and equipment can contact OTIP at 1-866-783-6847.
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.
Yes, the ETFO ELHT Plan has a mandatory generic drug requirement. This means that if there is a generic drug related to a brand name originator drug, the plan will reimburse the cost of the generic drug. A plan member may choose to continue on the brand name drug, but will be required to pay the difference between the generic drug and the brand name drug. Approved generic drugs are considered by the government to be interchangeable. If a new generic drug becomes available where one was not available before, plan members or their dependants will be required to switch to the generic drug in order to have full coverage of the drug.
In rare cases, a plan member or their dependant may have tried the generic drug and is unable to tolerate it for medical reasons (e.g. allergy to a filler in the generic drug; experience side-effects). In cases such as this, plan members are able to appeal using a one-page medical form to be completed by their treating physician and submitted to OTIP. Please click here to download the form (703kB PDF). Manulife will review the form and communicate whether an exception has been granted due to medical necessity.
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.
Premiums:
If you are in an eligible 1.0 FTE position, there is no cost for health, dental, basic life and AD&D coverage while you are actively at work. If you are working in an eligible part-time FTE position, you are required to pay a pro-rated premium (e.g. 0.5 FTE would pay 50% of the monthly premium; 0.2 FTE would pay 80% of the monthly premium, etc.) if you wish to participate in benefits.
If you are an eligible part-time member (e.g. 0.2, 0.5 FTE, 0.7 FTE, etc.), please see the documents below for information about pro-rated premiums:
*Teachers/LTO Plan Premiums: PDF (262kB)| Word (168kB)
*Education Plan Premiums: PDF (266B)| Word (198kB)
*The above premium rate documents are effective September 1, 2024 and are subject to change annually at renewal.
Alternately, plan members who are working in part-time assignments may opt out of benefits. If they opt out, they can only opt back in without medical evidence of insurability within 31 days of a change in FTE (i.e. increase or decrease) or experiencing a life event (e.g. marriage/common law qualification, birth/adoption, loss of spousal benefits).
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.
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:
Wave 1 – November 2016: Halton, Kawartha Pine Ridge, Ottawa Carleton, Peel, Rainbow, Renfrew, Simcoe County, Thames Valley and Waterloo Region district school boards.
Wave 2 – February 1, 2017: Algoma, Bluewater, Niagara and Ontario North East district school boards.
Wave 3 – April 1, 2017: Avon Maitland DSB, Durham DSB, Durham CDSB, Grand Erie DSB, Greater Essex County DSB, Hamilton-Wentworth DSB, Limestone DSB, Toronto DSB, Toronto CDSB, Trillium Lakelands DSB, Upper Grand DSB, Bloorview School Authority and John McGivney Children’s Centre School Authority.
Wave 4 – June 1, 2017: Hastings-Prince Edward DSB, Lambton Kent DSB, Keewatin-Patricia DSB, Lakehead DSB, Moosonee, Moose Factory, Near North DSB, Rainy River DSB, Superior-Greenstone DSB, Upper Canada DSB, York Region DSB, Campbell Children’s School Authority, KidsAbility Education Authority, Niagara Peninsula Children’s Centre School Authority and Penetanguishene Protestant Separate School Board.
Wave 5: Eligible Retirees – TBD
The funding that was negotiated allows for a comprehensive overall plan for the majority of ETFO members and is meant to address changing health and dental needs throughout a member’s career. Benefits should be viewed over the course of a career. As members progress through their career, their benefit needs and/or priorities change. What’s important to a member in a benefit plan at a certain date in time may be very different at another date in time and therefore focusing on one specific benefit does not reflect the overall quality of the Plan. An improvement for many members is an expanded scope of paramedical coverage. The inclusion of occupational therapy, nutritionists, registered social workers, family therapists and athletic therapists was new for many plan members.
The ELHT Plan does not include employee assistance programs (EAP). Boards are required to continue any programs they have in place.
Yes, under the ETFO ELHT Plan, two ETFO members can enrol in their own plans and list each other as dependants.
Members are guaranteed to maintain their previous levels of life insurance without providing evidence of medical insurability. Anything in addition to the 1x salary basic life that is part of the ETFO Benefits Plan would be 100% member paid. Member paid life insurance is a non-taxable benefit and as a result, the benefit amount paid to your estate is not subject to income tax.
If you currently do not have more than the 1x salary basic life, evidence of insurability will be required.
If you currently have more than the 1x salary basic life and want to add supplemental coverage and/or implement or increase your option life coverage amount, you will need to provide evidence of insurability. You will need to provide that evidence within 31 days from the transition start date of the Plan. OTIP will ensure that deadline is extended if you did not receive an OTIP enrolment email or your personal information on the OTIP portal was inaccurate and resulted in the inability to select insurance.
Except for orthodontic coverage, claims activity under a member’s previous plan does not have an impact on eligibility for claims under this plan.
Yes, the trustees of the ETFO ELHT have approved an ongoing appeal process.
Standard Process in Appealing a Claim