EXTENDED HEALTH BENEFITS 101

Reimbursement for the services of a licensed dental practitioner for dental care when required by a direct blow to the mouth and not by an object consciously or unconsciously placed in the mouth. The accident must occur while the coverage is in force. You must notify GSC immediately following the accident and the treatment must commence within the timeframe indicated in your benefit booklet.

A hearing aid is a small electronic device that can be worn in or behind the ear. It consists of three basic parts: a microphone, amplifier and speaker. A hearing aid may be required if an audio specialist has determined that you have a loss of hearing acuity. To determine specific benefit coverage based on your individual plan design, contact our customer service center.

A custom-made orthotic is made using raw materials created from a three-dimensional image or cast, so that it is specific to each individual. It serves as a device inserted into a person’s shoe that is intended to assist in the accommodation of specific foot deformities or disorders. In visiting an Orthotic provider, you should ensure one of the following professionals is on site during all business hours: Chiropodist, Podiatrist, Chiropractor, Medical Doctor, Pedorthist or Certified Orthotist. These professionals are Regulated Health Practitioners and therefore, GSC is better positioned to control the quality of care delivered to you, and monitor the product offered by them.

A professional land or air ambulance to the nearest hospital equipped to provide the required treatment, when medically required as a result of an injury, illness or acute physical disability.

A home care benefit provides coverage for the services of a Registered Nurse, or a Registered Practical Nurse on some plans, in the home. These services are only a benefit when medically necessary and only when the services required cannot be performed by someone with lesser qualifications. Various plans may have the added benefit of a Personal Support Worker. Pre-approval with GSC is required for this benefit.

• Private – we define private hospital accommodation as a private room with one bed in a public general hospital.
• Semi-Private – we define semi-private hospital accommodation as a room with no more than two beds, sharing one bathroom.
• Ward – we define ward hospital accommodation as a room with three or more beds in a public general hospital.

Upon discharge, remember to ask to see a copy of the accommodation charges to verify that they are charging you for exactly what you received. Your hospital may send a claim through directly to GSC as semi-private, without even verifying the room type that you actually received. If your doctor requests a private or semi-private room (preferred accommodation) for you for medical reasons, neither you nor GSC should be billed for these room charges. Your Provincial Health Insurance Plan will cover this benefit. GSC will only pay for preferred accommodation (a private or semi-private room) upon patient choice and provided the patient has signed a request for such accommodation. You should also not be charged for ward accommodations (three or more beds in a room), ICU (Intensive Care Unit) beds, CCU (Critical Care Unit) beds, or outpatient beds for day surgery. When a mother and her newborn occupy the same room, only one claim should be billed.

Medical items required due to medical necessity to assist with mobility, or to help correct a medical condition may be eligible through a benefit plan. Items that are not primarily medical in nature or that are for comfort and convenience are not eligible. A physician’s authorization may be required for various medical items, and specific medical items may require pre-approval. GSC does not reimburse claims for used medical equipment.

The following is a list of some of the more common paramedical practitioners (health care professionals) and their related health professional services. A physician’s authorization may be required on the initial claim. GSC requires that a paramedical practitioner be licensed in the province in which they are practicing.

• Acupuncturist – Acupuncture is an all-natural form of Chinese medicine which involves inserting needles into a patient’s skin at specific areas of the body, to concentrate on the points in need of healing. Acupuncture is used to improve a patient’s mood or energy levels, relieve pain, and restore function of the affected areas.
• Chiropractor – Chiropractors are medical professionals trained to diagnose and treat conditions related to the spine, and other body joints, by manipulating and correcting the alignment of the spinal column. They primarily treat disorders related to the back, neck and head pain. Chiropractors also counsel patients on corrective exercises and nutrition.
• Homeopath – Homeopathic medicine stems from the idea that the natural tendency of the body is to heal itself. It acknowledges that all symptoms of ill health are the body’s expressions of imbalances within itself, and that it is the patient who needs treatment, not the disease. Homeopathy is typically recommended for patients who have tried conventional treatments which have not been successful.
• Massage Therapist – A message therapist manipulates the soft tissues of the body in efforts to relieve muscle tension and bodily discomforts. Registered Massage Therapists (RMT) use their in-depth knowledge of anatomy, physiology and pathology to adjust the soft tissue in a scientific manner to break the pain cycle and bring about results. Massage therapy can help give patients relief from muscle spasms, tension in the neck and back, tired hands and feet, headaches, sports injuries, etc.
• Naturopath – Naturopathic medicine combines modern scientific health knowledge with traditional and natural remedies. The naturopathic philosophy is to treat the underlying cause of the disease. Symptoms are viewed as warning signals of malfunctions within the body, and poor lifestyle habits. Many people visit a naturopath on a regular basis to find out how to maintain good health. Naturopaths help manage patient concerns on a variety of health issues, from allergies and digestive problems to depression and more serious illnesses. Supplements and remedies are not eligible benefits under any GSC plan.
• Osteopath – An osteopath treats diseases by manipulation of the bones. Osteopathy is based on the theory that the body will produce the remedies necessary to protect it as long as the bones are aligned properly and do not press on the nerves. Osteopaths treat patients using a combination of gentle stretching, massage and mobilizing joints to ease symptoms. Commonly, patients visit the osteopath to seek relief from back pain, stiff joints, headaches, arthritis, fatigue or digestive issues.
• Physiotherapist – A physiotherapist uses a combination of comprehensive knowledge of how the body works and practical clinical skills to diagnose and treat injuries and illness. They work towards maximizing patient strength, mobility and well-being. A physiotherapist prescribes customized exercises as well as educates patients on essential steps to recovery.
• Podiatrist – Podiatry is a specialized medical field that centres around the study and care of the foot and ankle. A podiatrist focuses on preventing, diagnosing and treating conditions of this area by medical, surgical or other means.
• Reflexologist – Reflexology is a focused pressure technique, usually directed at the feet or hands. It is based on the premise that there are zones on different parts of the body which correspond to and are relative to all parts, glands and organs of the entire body. Common illnesses which can be treated by reflexology are blood circulation issues, digestive problems, nervous system conditions, weight management and migraines, to name a few.
• Speech Therapist – Speech therapists work to prevent, identify and treat communication and swallowing disorders as well as counsel patients and their families on their conditions. Speech therapists assess each patient’s individual needs and implement custom speech and language programs in efforts to help develop effective communication.

This is the “reasonable” reimbursement amount determined by GSC for a medical item or service. GSC establishes reasonable and customary pricing for all covered health services and major medical equipment. We determine our reasonable and customary pricing based on reviewing rendered amounts, manufacturers’ pricing and provincial and association pricing. In all cases, we reimburse the lesser of either the submitted or the allowed unit cost per device or service, as determined by our reasonable and customary pricing policy. Our reasonable and customary pricing policies are reviewed on an annual basis.

Here are some services and products you might come across if you have vision benefits:

• Prescription eyeglasses or contact lenses
• Replacement parts to prescription eye glasses
• Medically necessary contact lenses when the visual acuity cannot be corrected to at least 20/40 in the better eye with conventional eyeglasses
• Plano sunglasses prescribed by a medical practitioner for the treatment of ophthalmic diseases or conditions
• Some plans also allow reimbursement toward laser eye surgery in lieu of vision benefits (at the same benefit level). Laser vision correction is used to correct common vision problems, such as myopia (near sightedness), hyperopia (far-sightedness) and astigmatism (distorted vision when looking at objects in the distance).