Do you coordinate your Extended Health and Dental Care claims? Important changes on how reimbursement is calculated
RSB (Retirement & Survivor Benefits) plan members who are enrolled in more than one Extended Health or Dental Care plan have the ability to coordinate reimbursement between their plans (for example, between your RSB plan (primary plan) and your spouse/partner’s employer/retirement plan (secondary plan)). This allows for the portion of an eligible claim that is not paid by the first plan to be submitted to the second plan for consideration for reimbursement and may allow for up to 100% of the reasonable and customary amount* of the claim to be paid.
Effective Dec. 1, 2015, any amount that Sun Life reimburses as the second payer will be calculated based on the reasonable and customary amount of the expense instead of the submitted amount.
Example: Your spouse recently went to see a physiotherapist and was charged $90 for the visit. The claim was first submitted by your spouse to their employer/retirement’s extended health plan, which reimbursed $50. The remaining $40 was then submitted to the RSB plan.
The RSB plan is the second payer and will calculate the amount eligible for reimbursement as follows*:
These changes were made by Sun Life to align with industry practice. The impact will be minimal or none if your health practitioner, pharmacist or dentist charges at or below the reasonable and customary amount. If they charge above reasonable and customary, you will be responsible for the additional cost.
You can view a list of reasonable and customary charges for common paramedical practitioners on the UBC Benefits website, or contact Sun Life directly at 1-800-361-6212.
*Reasonable & customary amount:
There is a range of fees that are typically charged for items/services covered under Extended Health plans in each province. Sun Life and other insurance companies use these "reasonable and customary" fees as the basis for pricing their benefit plans and paying claims.
A reasonable and customary limit applies to all eligible expenses under Extended Health and Dental Care plans (for example, prescription drugs, paramedical services, medical equipment and supplies, hospital room rates, other services such as eye exams, eyewear, ambulance charges, dental procedures, etc).
Applying a reasonable and customary limit to a medical expense ensures that the group policy only reimburses the cost of a service or supply that is reasonable and typically charged in the geographic region in which the expense was incurred. It protects the plan against excess costs a provider may charge a customer with insurance, versus a cash-paying customer.
- Current reasonable and customary amount for physiotherapy in British Columbia: $80
- Maximum eligible for reimbursement under the RSB extended health plan: $80
- Amount reimbursed by spouse’s extended health plan: $50
- Amount reimbursed by RSB extended health plan = $80 minus $50 = $30
Prior to the change, the amount reimbursed would have been $40 ($90 – $50) and based on the amount submitted ($90), rather than the reasonable & customary charge ($80).
Extended Health Care Coverage Requirements
As a Canadian resident, you must be covered by your provincial health care plan to be eligible for coverage under a Sun Life group extended health care benefit
About Extended Health Care
Your employer’s Extended Health Care benefit is meant to supplement coverage provided under your publicly-funded provincial health care plan. This way, you and your dependents have financial assistance for many of your regular and catastrophic medical expenses from both your provincial government plan and your private group insurance plan.
What you need to do
It is important that you are enrolled continuously in your province’s health care plan: active enrollment is mandatory to be eligible for coverage under your employer’s Extended Health Care program.
You can visit your provincial government health plan website, or contact your local provincial office to understand the rules and criteria to keep your provincial health care coverage in place for you and your dependents – both at home and when you travel.
Remember to notify your plan administrator immediately (604-822-4580) if there has been any change to your (or your dependent’s) provincial plan coverage.