Supplemental health plan

The McGill Supplemental Health Plan provides protection for a range of medical items, services and procedures not covered under your provincial plan. To qualify for coverage under this plan, you and your eligible spouse and children must qualify for provincial health care benefits.

Mandatory Participation

Quebec legislation requires that you, your spouse and children must be covered under a group health insurance plan providing at least drug coverage if you are under age 65 and are eligible for coverage under that plan.  Only those employees who can provide proof they have health coverage under another plan are exempt from being charged the health insurance premium. See the RAMQ website for more information.

You can refuse participation in the McGill Health Plan if you provide proof of alternative health coverage (eg. through your spouse or through memberhip in a professional order or association). Complete the form confirmation_alternative_health_coverage.pdf  and return it to the HR Service Centre.

Coverage

Unless otherwise indicated, your McGill plan covers reasonable and customary charges for 100% of semi-private hospital and out-of-country emergency medical services, 80% of the cost for services of eligible medical practitioners, and 75% of the cost of eligible medical services and supplies.

What is reasonable customary?

These are charges, as determined by the insurer, that fall within the usual range of charges for the same or comparable service or supply. The determination takes into account the standing of the practitioner who provides the service and the geographic area in which the charge is incurred.

Out of Pocket Maximum

• If you have single coverage — the out-of-pocket maximum is $400 per benefit year.
• If you have family coverage — the out-of-pocket maximum is $800 per benefit year.

The out of pocket amount is the percentage you pay for services reimbursed at 75% or 80%. Once you reach the out-of-pocket maximum, all expenses for the remainder of the year will be reimbursed at 100%.

Note: All dollar maximums,frequency limits, reasonable and customary fees and any other contractual limitations still apply.

What the plan covers

Your McGill plan covers reasonable and customary charges for semi-private hospital accommodations, prescription drugs, health practitioners' services and a range of medical supplies and services not covered under your provincial plan, as outlined below.

A. Hospital services (100%)

Semi-private hospital (in Canada)

The plan covers 100% of the difference between the regular ward rate reimbursed through the provincial plan and the semi-private room rate charged by a licensed hospital. This includes hospital out-patient services.

For information on chronic, convalescent and rehabilitative hospitals, see "Supplies and services" below.

B. Prescription drugs (80%)

The plan covers the following expenses provided that they are prescribed in writing by a doctor (or dentist where appropriate):

• drugs or medicines required for therapy. To qualify, the drugs must
• • require the written prescription of a physician (or dentist) by law and convention and
  • be dispensed by a licensed pharmacist

• If a generic equivalent exists for a brand name drug, the cost of the generic equivalent will be reimbursed (unless the doctor indicates 'No Substitution' or 'No Generic' on the prescription).

• drugs for the treatment of infertility up to a lifetime maximum of $2,400 for each person
• insulin, including needles, syringes, reagent strips, cotton and alcohol swabs for the treatment of diabetes
• life-sustaining drugs
• oral contraceptives
• vaccines and compound serums that require a prescription.
• Anti-obesity drugs, Xenical and Meridia, up to a lifetime maximum of $2,400

The plan does not cover:

• anti-obesity treatments, other than Xenical and Meridia for each person
• anti-impotence treatments
• anti-smoking treatments
• baby foods and formula
• cough medicines
• dietary food supplements, minerals, proteins, vitamins and collagen treatments
• hair growth stimulants
• medicines obtained directly from a doctor or dentist
• patent or proprietary medicines you can obtain without a prescription, including over-the-counter drugs
• the cost of giving injections, serums or vaccines
• drugs dispensed and distributed through prescription on-line sites(Internet pharmacies)

C. Health practitioners (80%)

The plan covers the following reasonable and customary services when REFERRED BY A DOCTOR, subject to the outlined limits and restrictions:

Private duty nursing — up to $30,000 during any consecutive 60-month period for nursing care performed at the patient's residence (other than a convalescent or nursing home). The service must be authorized, in writing, by the attending physician. (Services that are for custodial care, eg. personal hygiene, meal preparation, help with mobility, are not covered.)

Nursing services must be provided by a Registered Nurse, Registered Nursing Assistant or Registered Trained Attendant who is not related to or living with the patient. You must submit a Pre-Determination form to the insurer before the nursing services can begin. For details, please refer to the Submitting Claims section of this website.

The plan also covers the following reasonable and customary services WITHOUT A DOCTOR'S REFERRAL:

Psychological services — 80% of eligible expenses up to an annual maximum of $1,000 per person each benefit year for the services of a licensed psychologist, or a social worker who is a member of the Order of Social Workers.

Physiotherapy, occupational therapy, athletic therapy, or speech therapy. — for services performed by a physiotherapist, occupational therapist, certified athletic therapist, or licenced speech therapist up to a combined maximum of $750 per person each benefit year.

Chiropractors, osteopaths, acupuncturists, or dieticians — up to a combined maximum of $300 per person each benefit year. This includes one x-ray per benefit year by each licensed practitioner.

Psychoanalysis — up to $15 per visit for psychoanalytic treatment at home or office. This treatment must be provided by a member of the Canadian Psychoanalytic Society or similar society outside of Canada.

D. Supplies and services (75%)

The plan covers the following medical supplies and services when prescribed by an appropriate medical practitioner (subject to the outlined limits and restrictions):

Accidental dental — charges for dental treatment required to repair natural teeth damaged by an external, sudden and violent blow to the mouth. These services must be provided within six months of the date of the accident. Reimbursements will be limited to the current fee guide for dental services provided by general practitioners published by the Quebec Dental Surgeons Association.

Ambulance services — charges for licensed ambulance services required to transport a stretcher patient to and from the nearest licensed hospital able to provide essential care. This includes charges for licensed air transport to the nearest licensed hospital for necessary emergency care.

Artificial limbs and eyes — including necessary replacements (does not include myoelectric appliances).

Casts, splints, trusses and braces.

Convalescent and rehabilitative hospitals — the plan also covers the cost of the semi-private room charge for a stay in a chronic, convalescent or rehabilitative hospital, provided the stay is:

• ordered by a doctor
• begins within 14 days of leaving a licensed hospital
• is primarily for rehabilitative treatment (rather than custodial care).

This coverage is limited to 120 days per disability.

Colostomy and ileostomy supplies — charges for essential colostomy and ileostomy supplies.

Diabetic supplies - such as needles, syringes, reagent strips, cotton and alcohol swabs for the treatment of diabetes.

Diagnostic Services — when carried out in a private laboratory or clinic in the province of Quebec that is, in the insurer’s opinion, qualified to provide the required services. Covered services include, but are not limited to, the following: laboratory tests, x-ray examinations, ultrasound and MRIs. These services are covered up to a maximum of $750 per person, per benefit year. Tests performed in a doctor's office or a pharmacy are not covered.

Durable medical equipment — the rental (or purchase when approved by the insurer) of manual hospital beds, respiratory and oxygen equipment, and other durable equipment usually found only in hospitals. The purchase of one insulin pump per lifetime of the insured and related medical supplies.

Intra-ocular lens - required as a result of cataract surgery to a limit of one lens per eye during the lifetime of the insured.

Elastic support stockings — up to $50 per person each benefit year.

Eye Exams — 100% of the cost of an eye exam rendered by a licensed optometrist or an ophthalmologist registered under Medicare limited to a maximum of $70 once every 24 consecutive months. Please refer to the Submitting Claims section on this website for specific requirements for claims payment.

Glucometers — up to $200 per person every 36 consecutive months when prescribed in writing by a medical doctor.

Hearing aids — up to $500 per person in any five consecutive years. The aid must be prescribed in writing by an otolaryngologist. The plan does not cover batteries and professional services.

Mammary prostheses — required as the result of surgery, to a limit of two prostheses per person each benefit year. The maximum cost for each prosthesis is limited to $200.

Mobility equipment — the rental or purchase (when approved by the insurer) of crutches, canes, walkers and non-motorized wheelchairs.

Orthotic inserts for shoes or orthopaedic shoes — up to one custom-made pair per person each benefit year. The devices must be made in a specialized orthopaedic laboratory and must be prescribed by a physician, podiatrist or chiropodist. As well, orthotics and orthopedic shoes must be dispensed by an Orthotist, Pedorthist, Podiatrist or Chiropodist. Please refer to the Submitting Claims section on this site for specific requirements for claims payment.

Oxygen, plasma and blood transfusions.

Radiotherapy or coagulotherapy services.

Wigs and hairpieces — for patients with temporary hair loss resulting from chemotherapy, up to a lifetime maximum of $200 per person.

E. Out-of-country/province services (100%)

Reminder:
Unstable political and environmental conditions in some countries may affect availability of emergency medical or assistance services.

For more info on travel conditions, consult the Travel Bulletin, published by the Consular Affairs Bureau, Federal Dept of Foreign Affairs. For more info on the availability of World Access services in a particular country, please call their 24-hour help line.

Emergency travel assistance

This plan offers you and your eligible spouse and children emergency medical coverage for medical services required due  to an unforeseen illness or injury while travelling outside of Canada or your province of residence. The plan is subject to a lifetime maximum of $5,000,000 per person.

Coverage  

Coverage is limited to trips of a maximum 90 days duration.  If you are travelling on University business/sabbatical - refer to the section Employee Business Travel.

Important! Temporary Residents take note:
If you are a temporary resident - coverage is limited to trips of a maximum 21 days duration. (RAMQ) imposes a 21-day travel restriction rule. For more information, refer to the RAMQ website.(Persons staying in Quebec temporarily). Since you must have provincial plan health care in order to be covered by the McGill Supplemental Health Plan, if you remain outside the province for longer than 21 days, you will not be covered during your absence (the usual 90 day limit does not apply).

Definition of Medical Emergency

A Medical Emergency occurs when an insured person requires immediate medical attention while an insured person is travellinig outside his province of residence due or related to:

1) A sudden, unexpected injury which occures or a new medical condition which egins while an insured person is travelling outside his province of residence; or
2) A previously indentified medical condition that was Stable, but not diagnosied as terminal or prescribed for palliative care, at the time of departure from his province of residence.

For a definition of a stable medical condition refer to Manulife's Travel Bulletin:travel_bulletin_manulife_plan_members.pdf

A medical emergency no longer exists when, in the opinion of the attending physician and supporting medical evidence, the insured personis able to return to this province of residence. 

Pregnancy:   Coverage is available for medical emergencies related to pregnancy as long as travel is completed at least 4 weeks prior to the due date. No coverage is provided for any medical emergency related to a pregnancy for insured persons who are pregnant and travelling within 4 weeks of the due date.

Benefits covered

The plan covers 100% of the following benefits, provided the services are ordered by a doctor (or dentist where applicable) and provided part of the charge is payable under the provincial health plan in the province of residence:

• emergency hospital expenses incurred during the first 90 days of a trip outside of Canada, but not lasting beyond 14 days, unless the attending doctor (M.D.) certifies that the covered person should not be moved back to his/her home province
• charges in accordance with the average rate for semi-private hospital accommodations in the locality where the facilities and services are provided. This includes any admittance, coinsurance or utilization charges where permitted by law
• other hospital services
• hospital out-patient services
• services of a doctor (reasonable and customary charge according to locality).

CALL Allianz Global Assistance:   If you require medical services due to an unforeseen illness or injury while travelling. It is important that you carry your Manulife drug/travel card with you at all times. Contact Allianz Global Assistance directly at one of the numbers listed on your card. Be sure to quote the Plan ID number 9505, as well as your Manulife Plan Contract Number 85210.

Manulife's Emergency Travel Assistance Manulife enhances the emergency travel insurance coverage provided by your McGill Supplemental Health Plan. For further information, please consult Manulife's Emergency Travel Assistance

Employee business travel

If you are travelling on University business (such as on sabbatical leave), coverage will continue past the first 90 days of your trip until you return, provided you remain eligible for provincial health care coverage (Quebec Health Insurance Plan). To remain covered by the Québec Health Insurance Plan, your stay outside the province must be less than 183 days in any given calendar year (Jan-Dec). 

If you plan to be outside the provinde for 183 days or more, you must contact the RAMQ BEFORE you leave.  Refer to their website for more information.

Important! Temporary Residents take note:
If you are a temporary resident - coverage is limited to trips of a maximum 21 days duration. (RAMQ) imposes a 21-day travel restriction rule. For more information, refer to the RAMQ website.(Persons staying in Quebec temporarily). Since you must have provincial plan health care in order to be covered by the McGill Supplemental Health Plan, if you remain outside the province for longer than 21 days, you will not be covered during your absence (the usual 90 day limit does not apply).

Staff members travelling on University business are also covered for emergency medical expenses related to war and terrorism. This coverage is provided through CHARTIS and supplements Manulife Financial's regular Travel Assistance program.

CHARTIS requires information pertaining to the travel arrangements of each staff member. Therefore, to ensure that staff members are fully protected, it is imperative that the following information be sent to the HR Service Centre prior to departure:

• Employee's Name
• Employee's ID number
• Employees's Date of Birth
• Employee's Destination
• Length of trip (eg. the departure date and the return date)

You may register this information on the Emergency Travel Assistance page.  You may also send this information by fax (514) 398-8287 or by internal mail to the HR Service Centre, 688 Sherbrooke St. W., 15th Floor, Rm 1520, Montreal, Qc. H3A 3R1

If you require medical services for an unforeseen illness or injury while you are travelling on University business: It is important that you carry your Manulife drug/travel card with you at all times. Contact Allianz Global Assistance directly at one of the numbers listed on your card. Be sure to quote the Plan ID number 9505, as well as your Manulife Plan Contract Number 85210. If it is evident that emergency medical services are required due to an act of war or terrorism, Manulife Financial will contact CHARTIS.

Claiming expenses for emergency out-of-country medical services

Obtain a fully itemized bill for any hospital treatment provided

Keep all receipts

For expenses $200 or less:

You must file a claim first with your provincial health care plan (eg. RAMQ in Quebec) and then with Manulife for the balance.

    1. Attach the original receipt(s) to the appropriate provincial health plan claim form for your province of residence. Keep a copy of all documents to send to Manulife once you receive settlement from the provincial health care plan.
    2. Sign, date and forward this form along with the original receipts to your provincial health plan (e.g., RAMQ — Régie de l'assurance-maladie du Québec)
    3. Once you receive payment from your provincial health plan, submit any unpaid balance to Manulife. Attach copies of the receipts and the Statement of Expenses indicating amounts considered and paid under your provincial health care plan.

For expenses in excess of $200:

Allianz Global Assistance will assume responsibility on your behalf for obtaining reimbursement of eligible medical expenses from your provincial health care plan and from Manulife.  You must however have contacted them when medical services were incurred.

Non-emergency referrals

The plan covers the following benefits for charges incurred for care unavailable in Canada, when referred to by a licensed doctor (M.D.) and approved in advance by the provincial health plan and the insurer, but not beyond 60 days, and provided part of the charge is payable under the provincial health plan of the province of residence:

• charges in excess of the ward rate under the provincial health plan for hospital accommodations up to a daily maximum of $100
• other hospital services
• hospital out-patient services
• services of a doctor (reasonable and customary charge according to locality).

What the plan doesn't cover

In addition to any exclusions listed on the previous pages, the plan does not pay any benefit or accept liability for claims for the following:

• any portion of an eligible expense which is in excess of the reasonable and customary charge for the services or supplies in the locality where the service is provided
• equipment such as orthopaedic mattresses, exercise equipment, whirlpools, air-conditioning and air purifying units, and any other equipment which the administrator considers to be an ineligible expense
• expenses for custodial care
• expenses incurred for psychological disorders, including functional nervous disorders if the expenses are incurred in an institution specializing in the treatment of the disorder or disease in question
• services of a naturopath, massage therapist or podiatrist
• eyeglasses, contact lenses, laser eye surgery and expenses of an opthtalmologist for services other than the actual eye exam
• hospital expenses incurred while travelling outside the country (other than for referrals or emergency treatment)
• medical expenses arising, directly or indirectly, from
  • war, insurrection or the hostile action of the armed forces of any country (except Employee Travel Assistance)
  • participation in a riot, civil commotion, or commission of a criminal offence
  • any cause for which benefits or compensation is provided under any workers' compensation law or similar legislation
• rest cure or travel for reasons of health
• services or supplies that are paid for under provisions of any government-sponsored plan or program
• treatment, surgery, care, service, examination or appliance, which is
  • not medically necessary
  • given or required for cosmetic purposes, except for dental treatment required as a result of an accident
  • given or required for reasons other than curative
  • given or required in relation to an operation or treatment of an experimental nature, or
  • in excess of what is ordinarily given or required in accordance with current therapeutic practice
• treatment or appliance (related directly or indirectly to full mouth reconstruction) to correct vertical dimension and temporomandibular joint dysfunction.
• charges of an ophthalmologist for services other than the actual eye exam (eg. eye drops)
• Effective January 1, 2010: Charges for a brand name drug when a generic equivalent exists. The generic equivalent will be reimbursed.
• Doctors fees: example (but not limited to) private doctor visits; fees incurred to perform a medical procedure - other than those covered under Out-of-country/province – Emergency travel assistance

Paying for your coverage

The amount you pay for your coverage will depend on whether you select coverage for:

• you alone ("single" coverage) or
• you and your eligible spouse and children ("family" coverage).

For definitions of "spouse" and "children", please refer to Defining your "family". Similarly, see Rate summary for plan costs.

Opting out

You may opt out of the Supplemental Health Plan if you can provide written evidence that you are covered under another supplemental health plan -- eg. as a dependent under your spouse's plan. See details in Life Events.

When coverage ends

Your coverage under the plan will end when you leave the University (before retirement), fail to qualify for coverage under the terms of the plan, or opt out of the plan altogether.

Coverage for your spouse and children will end when yours does. In addition, coverage will end on an individual basis when your family members are no longer eligible under the terms of the plan — for example, when a son or daughter marries or begins full-time employment.

Please refer to Life events for more details.

If you become disabled

Your coverage under the Supplemental Health Plan will continue while you are eligible for benefits under the Long-Term Disability Plan, provided you continue to pay your share of plan costs.

If you die

If you die before retirement and you had family coverage, your spouse and eligible dependent children can choose to continue coverage under the Plan for up to three months, provided they pay both their share and the University's share of the cost.