Jump to Plan Details after the first 12 months of services
Plan Details For The First 12 Months of Services
Services shown below will be eligible if they are usual, reasonable and customary, and are medically necessary for the treatment of an illness or injury. Please contact your benefits administrator or Green Shield Canada (GSC) Customer Service Centre at 1.888.711.1119 to determine benefit eligibility and coverage details. All claims must be received by GSC no later than 12 months from the date the eligible service was incurred.
Co-pay is the eligible allowed amount that must be paid by you or your dependent before reimbursement of an expense will be made.
TERMINATION
Your coverage will end on the earliest of the following dates:
- a) the date of your death;
- b) the end of the period for which rates have been paid to GSC for your coverage; or
- c) the date the group contract terminates.
DENTAL
- Deductible: Nil
- Maximum plan pays: Unlimited
- Stated maximums are expressed in Canadian dollars
- Your co-pay: 30% for Basic services and 30% for Comprehensive basic services
- Basic services cover recalls once every 9 months, other exams and full mouth X-rays every 3 years
- Comprehensive basic services cover denture relines once every 3 years
- Applicable lab, drug and other expenses are eligible to a maximum of 40% of the allowable professional fee. Any applicable co-payment is then applied
- Your eligible claims are reimbursed at the level stated above and in accordance with: the current Provincial Dental Association Fee Guide for General Practitioners in the province where services are rendered
- for independent Dental Hygienists, the lesser of the current, Provincial Dental Hygienists’ Association Fee Guide and Provincial Dental Association Fee Guide for General Practitioners in the province where services are rendered
- for Alberta, with no fee guide, reimbursement will be according to a fee schedule established by GSC for that province.
Basic Services
- Recalls include exams, bitewing X-rays, preventive cleanings and fluoride treatments
- Complete, general or comprehensive oral exams, full mouth X-rays and panoramic X-rays
- Basic restorations, fillings and inlays
- Extractions and surgical services
- General anaesthesia, deep sedation, and intravenous sedation in conjunction with eligible oral surgery only
Comprehensive Basic Services
- Endodontic treatment including standard root canal therapy, excluding retreatments
- Periodontal treatment including scaling and/or root planing
- Standard denture services including: – relining and rebasing of dentures only after 6 months have elapsed from the installation of a denture
- denture adjustments only after 3 months have elapsed from the installation of a denture
Alternate Treatment
The group benefit plan will reimburse the amount shown in the Fee Guide for the least expensive service or supply, provided that both courses of treatment are a benefit under the plan.
Predetermination
Before your treatment begins, if the total cost of any proposed treatment is expected to exceed $300, it is recommended that you submit an estimate completed by your dental practitioner.
GENERAL INFORMATION
GENERAL OVERALL EXCLUSIONS
Eligible Services do not include and reimbursement will not be made for:
1. services or supplies received as a result of disease, illness or injury due to:
a) an act of war, declared or undeclared;
b) participation in a riot or civil commotion; or
c) committing a criminal offence;
2. services or supplies provided while serving in the armed forces of any country;
3. failure to keep a scheduled appointment with a legally qualified medical or dental practitioner;
4. the completion of any claim forms and/or insurance reports;
3. any specific treatment or drug which:
a) does not meet accepted standards of medical, dental or ophthalmic practice, including charges for services or supplies which are experimental in nature, or is not considered to be effective (either medically or from a cost perspective, based on Health Canada’s approved indication for use);
b) is an adjunctive drug prescribed in connection with any treatment or drug that is not an eligible service;
c) is administered in a hospital or is required to be administered in a hospital in accordance with Health Canada’s approved indication for use;
d) is not dispensed by the pharmacist in accordance with the payment method used for Prescription Drugs;
e) is not being used and/or administered in accordance with Health Canada’s approved indication for use, even though such drug or procedure may customarily be used in the treatment of other illnesses or injuries;
6. service and charges for sleep dentistry;
7. services or supplies that:
a) are not recommended, provided by or approved by the attending legally qualified (in the opinion of GSC) medical practitioner or dental practitioner as permitted by law;
b) are legally prohibited by the government from coverage;
c) you are not obligated to pay for or for which no charge would be made in the absence of benefit coverage or for which payment is made on your behalf by a not-for-profit prepayment association, insurance carrier, third party administrator, like agency or a party other than GSC, your plan sponsor or you;
d) are provided by a health practitioner whose license by the relevant provincial regulatory and/or professional association has been suspended or revoked;
e) are not provided by a designated provider of service in response to a prescription issued by a legally qualified health practitioner;
f) are primarily for cosmetic or aesthetic purposes, or are to correct congenital malformations;
g) are provided by an immediate family member related to you by birth, adoption, or by marriage and/or a practitioner who normally resides in your home. An immediate family member includes a parent, spouse, child or sibling;
h) are a replacement of lost, missing or stolen items, or items that are damaged due to negligence.
i) are from any governmental agency which are obtained without cost by compliance with laws or regulations enacted by a federal, provincial, municipal or other governmental body;
j) would normally be paid through any provincial health insurance plan, worker’s compensation board or tribunal, the Assistive Devices Program or any other government agency, or which would have been payable under such a plan had proper application for coverage been made, or had proper and timely claims submission been made;
k) were previously provided or paid for by any governmental body or agency, but which have been modified, suspended or discontinued as result of changes in provincial health plan legislation or de-listing of any provincial health plan services or supplies;
l) may include but are not limited to, drugs, laboratory services, diagnostic testing or any other service which is provided by and/or administered in any public or private health care clinic or like facility, medical practitioner’s office or residence, where the treatment or drug does not meet the accepted standards or is not considered to be effective (either medically or from a cost perspective, based on Health Canada’s approved indication for use);
m) are provided by a medical practitioner who has opted out of any provincial health insurance plan and the provincial health insurance plan would have otherwise paid for such eligible service;
n) relates to treatment of injuries arising out of a motor vehicle accident;
o) are cognitive or administrative services or other fees charged by a provider of service for services other than those directly relating to the delivery of the service or supply.
CO-ORDINATION OF BENEFITS (COB)
Where you or your dependents have coverage with more than one carrier, claims will be co-ordinated so that reimbursement from all coverage will not exceed 100% of the actual claim. Visit our web site at greenshield.ca or call our Customer Service Centre at 1.888.711.1119 for information on COB.
SUBROGATION
GSC retains the right to subrogation if benefits have or should have been paid or provided by a third party. In cases of third party liability, you must advise your lawyer of these rights.
GROUP CONVERSION PACKAGE
If your group service terminates, you are eligible to continue benefits on an individual basis. You must apply within 60 days after the date your group benefits have been terminated.
ADDITIONAL BENEFITS
As a Green Shield plan member, you have access to our national preferred provider vision network arrangement where all Green Shield plan members are eligible to receive a discount on eyewear and laser eye surgery.
PLAN MEMBER ONLINE SERVICES
In addition to this booklet and our Customer Service Centre, we also provide you with access to our secure website. Self-service through the GSC website makes things quick, convenient and easy. Register today to:
- View your Benefit Plan Booklet
- Access your personal claims information, including a breakdown of how your claims were processed
- Simulate a claim to instantly find out what portion of a claim will be covered
- Submit certain claims online
- Search for a drug to get information specific to your own coverage (or coverage for your family)
- Search for eligible dental, paramedical, and vision care providers in a particular location (within Canada)
- Search for vision and hearing care providers who offer discounts to GSC plan members through our Preferred Provider Network
- Arrange for claim payments to be deposited directly into your bank account
- Print personalized claim forms and replacement Identification Cards
- Print personal Explanation of Benefits statements for when you need to co-ordinate benefits
Register online at greenshield.ca and see what our website can do for you!
Plan Details After The First 12 Months of Services
Services shown below will be eligible if they are usual, reasonable and customary, and are medically necessary for the treatment of an illness or injury. Please contact your benefits administrator or Green Shield Canada (GSC) Customer Service Centre at 1.888.711.1119 to determine benefit eligibility and coverage details. All claims must be received by GSC no later than 12 months from the date the eligible service was incurred.
Co-pay is the eligible allowed amount that must be paid by you or your dependent before reimbursement of an expense will be made.
TERMINATION
Your coverage will end on the earliest of the following dates:
- a) the date of your death;
- b) the end of the period for which rates have been paid to GSC for your coverage; or
- c) the date the group contract terminates.
DENTAL
- Deductible: Nil
- Maximum plan pays:
- Basic services and Comprehensive basic services: Unlimited
- Major services, excluding bridgework repair or recementing: $600 every 12 months based on plan member’s status effective date
- Stated maximums are expressed in Canadian dollars
- Your co-pay: 20% for Basic services, 20% for Comprehensive basic services and 50% for Major services*
- Basic services cover recalls once every 9 months, other exams and full mouth X-rays every 3 years
- Comprehensive basic services cover denture relines once every 3 years
- Major services cover standard dentures, crowns and bridges once every 5 years
- Applicable lab, drug and other expenses are eligible to a maximum of 40% of the allowable professional fee. Any applicable co-payment is then applied
- Your eligible claims are reimbursed at the level stated above and in accordance with: the current Provincial Dental Association Fee Guide for General Practitioners in the province where services are rendered
- for independent Dental Hygienists, the lesser of the current, Provincial Dental Hygienists’ Association Fee Guide and Provincial Dental Association Fee Guide for General Practitioners in the province where services are rendered
- for Alberta, with no fee guide, reimbursement will be according to a fee schedule established by GSC for that province.
Basic Services
- Recalls include exams, bitewing X-rays, preventive cleanings and fluoride treatments
- Complete, general or comprehensive oral exams, full mouth X-rays and panoramic X-rays
- Basic restorations, fillings and inlays
- Extractions and surgical services
- General anaesthesia, deep sedation, and intravenous sedation in conjunction with eligible oral surgery only
Comprehensive Basic Services
- Endodontic treatment including standard root canal therapy, excluding retreatments
- Periodontal treatment including scaling and/or root planing
- Standard denture services including: – relining and rebasing of dentures only after 6 months have elapsed from the installation of a denture
- denture adjustments only after 3 months have elapsed from the installation of a denture
Major Services
- Standard dentures, complete, immediate and partial
- Standard crown restorations or onlays on natural teeth (paid to full metal on molar)
- *Repair of crowns and onlays on natural teeth, subject to 20% co-pay
- Recementing of crowns and onlays on natural teeth
- *Repair or recementing of bridgework on natural teeth, subject to 20% co-pay
- Standard bridges, including pontics, abutment retainers/crowns on natural teeth (paid to full metal on molar)
Alternate Treatment
The group benefit plan will reimburse the amount shown in the Fee Guide for the least expensive service or supply, provided that both courses of treatment are a benefit under the plan.
Predetermination
Before your treatment begins:
– for all proposed treatment for crowns, onlays and bridges, an estimate completed by your dental practitioner, must be submitted for assessment. Our assessment of the proposed treatment, may result in a lesser benefit being payable or may result in benefits being denied. Failure to submit an estimate prior to beginning your treatment will result in the delay of the assessment.
– if the total cost of any other proposed treatment is expected to exceed $300, it is recommended that you submit an estimate completed by your dental practitioner.
GENERAL INFORMATION
GENERAL OVERALL EXCLUSIONS
Eligible Services do not include and reimbursement will not be made for:
- services or supplies received as a result of disease, illness or injury due to:
- a) an act of war, declared or undeclared;
- b) participation in a riot or civil commotion; or
- c) committing a criminal offence;
- services or supplies provided while serving in the armed forces of any country;
- failure to keep a scheduled appointment with a legally qualified medical or dental practitioner;
- the completion of any claim forms and/or insurance reports;
- any specific treatment or drug which:
- a) does not meet accepted standards of medical, dental or ophthalmic practice, including charges for services or supplies which are experimental in nature, or is not considered to be effective (either medically or from a cost perspective, based on Health Canada’s approved indication for use);
- b) is an adjunctive drug prescribed in connection with any treatment or drug that is not an eligible service;
- c) is administered in a hospital or is required to be administered in a hospital in accordance with Health Canada’s approved indication for use;
- d) is not dispensed by the pharmacist in accordance with the payment method used for Prescription Drugs;
- e) is not being used and/or administered in accordance with Health Canada’s approved indication for use, even though such drug or procedure may customarily be used in the treatment of other illnesses or injuries;
- service and charges for sleep dentistry;
- services or supplies that:
- a) are not recommended, provided by or approved by the attending legally qualified (in the opinion of GSC) medical practitioner or dental practitioner as permitted by law;
- b) are legally prohibited by the government from coverage;
- c) you are not obligated to pay for or for which no charge would be made in the absence of benefit coverage or for which payment is made on your behalf by a not-for-profit prepayment association, insurance carrier, third party administrator, like agency or a party other than GSC, your plan sponsor or you;
- d) are provided by a health practitioner whose license by the relevant provincial regulatory and/or professional association has been suspended or revoked;
- e) are not provided by a designated provider of service in response to a prescription issued by a legally qualified health practitioner;
- f) are primarily for cosmetic or aesthetic purposes, or are to correct congenital malformations;
- g) are provided by an immediate family member related to you by birth, adoption, or by marriage and/or a practitioner who normally resides in your home. An immediate family member includes a parent, spouse, child or sibling;
- h) are a replacement of lost, missing or stolen items, or items that are damaged due to negligence.
- i) are from any governmental agency which are obtained without cost by compliance with laws or regulations enacted by a federal, provincial, municipal or other governmental body;
- j) would normally be paid through any provincial health insurance plan, worker’s compensation board or tribunal, the Assistive Devices Program or any other government agency, or which would have been payable under such a plan had proper application for coverage been made, or had proper and timely claims submission been made;
- k) were previously provided or paid for by any governmental body or agency, but which have been modified, suspended or discontinued as result of changes in provincial health plan legislation or de-listing of any provincial health plan services or supplies;
- l) may include but are not limited to, drugs, laboratory services, diagnostic testing or any other service which is provided by and/or administered in any public or private health care clinic or like facility, medical practitioner’s office or residence, where the treatment or drug does not meet the accepted standards or is not considered to be effective (either medically or from a cost perspective, based on Health Canada’s approved indication for use);
- m) are provided by a medical practitioner who has opted out of any provincial health insurance plan and the provincial health insurance plan would have otherwise paid for such eligible service;
- n) relates to treatment of injuries arising out of a motor vehicle accident;
- o) are cognitive or administrative services or other fees charged by a provider of service for services other than those directly relating to the delivery of the service or supply.
CO-ORDINATION OF BENEFITS (COB)
Where you or your dependents have coverage with more than one carrier, claims will be co-ordinated so that reimbursement from all coverage will not exceed 100% of the actual claim. Visit our web site at greenshield.ca or call our Customer Service Centre at 1.888.711.1119 for information on COB.
SUBROGATION
GSC retains the right to subrogation if benefits have or should have been paid or provided by a third party. In cases of third party liability, you must advise your lawyer of these rights.
GROUP CONVERSION PACKAGE
If your group service terminates, you are eligible to continue benefits on an individual basis. You must apply within 60 days after the date your group benefits have been terminated.
ADDITIONAL BENEFITS
As a Green Shield plan member, you have access to our national preferred provider vision network arrangement where all Green Shield plan members are eligible to receive a discount on eyewear and laser eye surgery.
PLAN MEMBER ONLINE SERVICES
In addition to this booklet and our Customer Service Centre, we also provide you with access to our secure website. Self-service through the GSC website makes things quick, convenient and easy. Register today to:
- View your Benefit Plan Booklet
- Access your personal claims information, including a breakdown of how your claims were processed
- Simulate a claim to instantly find out what portion of a claim will be covered
- Submit certain claims online
- Search for a drug to get information specific to your own coverage (or coverage for your family)
- Search for eligible dental, paramedical, and vision care providers in a particular location (within Canada)
- Search for vision and hearing care providers who offer discounts to GSC plan members through our Preferred Provider Network
- Arrange for claim payments to be deposited directly into your bank account
- Print personalized claim forms and replacement Identification Cards
- Print personal Explanation of Benefits statements for when you need to co-ordinate benefits