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  3. AMAPCEO gets action: Customary limits removed for OPS members’ paramedical benefits

AMAPCEO gets action: Customary limits removed for OPS members’ paramedical benefits

Image of stacked stones on sand to represent news item on "AMAPCEO gets action: Customary limits removed for OPS members’ paramedical benefits"
Update

Wednesday, March 20, 2024

AMAPCEO is pleased to announce that as a result of a recent policy dispute settlement with the Ontario Public Service (OPS) Employer, the benefits provider Canada Life will no longer apply “reasonable and customary (R&C) limits” to eligible paramedical benefits for OPS members.  
 
How does this impact you?
 
Effective September 2, 2022, and going forward, all eligible paramedical service claims made for OPS members and their dependents will be reimbursed to either the per-visit or half-hour maximum rates defined in Articles 34.2 (e) and PT.10.3 (e) in the 2022–2025 AMAPCEO-OPS Collective Agreement up to the annual maximum for each service: 

  • an acupuncturist: $35 per visit, to an annual maximum of $1,200 
  • a speech therapist: $40 per half hour, to an annual maximum of $1,400 
  • a chiropractor, osteopath, naturopath, podiatrist, chiropodist, physiotherapist, and masseur: $35 per visit, to an annual maximum of $1,200

Example Scenario:

  • You were charged $80 for a 30-minute appointment for your child (dependent) with a Registered Massage Therapist (RMT).
  • The claim was first submitted to the other parent’s plan, because the other parent’s birthday is earlier in the calendar year than yours (per the coordination of benefit rules). 
  • The other parent’s plan covered $45 of the cost, which means you’re still $35 out of pocket ($80 - $45 = $35). 
  • You submitted the claim to Canada Life for the remaining amount.
  • Previously:
    • Canada Life may have asserted the “reasonable and customary” limit for a 30-minute RMT appointment was $72.
    • Since the other parent’s plan already paid $45, Canada Life would reimburse you for just $27 ($72 - $45 = $27).
    • You would still be out of pocket $8 ($80 - ($45 - $27) = $8)
  • Now:
    • Canada Life’s R&C limit no longer applies.
    • Since the other parent’s plan already paid $45, Canada Life must reimburse you $35, as that is what is covered under the Collective Agreement per visit with an RMT.

Reminder: OPS members can submit a claim to have the balance covered by their Health Care Spending Account, if they wish.
 
What about past claims?
 
 
Canada Life will be re-assessing and reprocessing all eligible claims submitted on or after September 2, 2022, and will make the necessary adjustments as soon as possible.  No further action is required on OPS members’ part. 
 
AMAPCEO is one of the few unions to successfully remove reasonable and customary benefit limits on paramedical services.

This change, coupled with the introduction of an annual Health Care Spending Account in the 2022–2025 AMAPCEO-OPS Collective Agreement, provides members more value from their medical benefits coverage.
 

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We would like to acknowledge Tkaronto, a Mohawk word meaning “the place in the water where the trees are standing.”

The AMAPCEO office is on the traditional unceded territory of Haudenosaunee speaking nations, including the Wendat, Seneca and Mohawk. These nations have been here since time immemorial and were in more recent times joined by the Mississaugas of the Credit.

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