Benefits

AMAPCEO benefit plans

AMAPCEO members have access to a number of different benefits plans, including:

• Dental
• Life insurance
• Long-term income protection
• Supplementary health and hospital (an umbrella category that covers prescription drugs, paramedical services, vision and hearing supports, supplies, equipment etc.)

AMAPCEO members in the Ontario Public Service (OPS) are also eligible for:

• Catastrophic drug coverage (covers annual drug expenses over $10,000 at 100 per cent, rather than the 90 per cent coverage under the regular prescription plan)
• Out-of-country emergency coverage 

Some AMAPCEO bargaining units also have access to a Health Care Spending Account (HCSA). This is not technically a benefit plan like those listed above. However, for our OPS members, appeals of denied HCSA claims can still be addressed at the Joint Benefits Review Committee. 

Collective agreement language constructs

When advising or representing a member on a benefits issue, it is important to know what collective agreement language “construct” the benefit falls into – meaning, whether the benefit in question is explicitly mentioned in the member’s collective agreement. 

In some cases, the collective agreement specifically details a benefit. 

• For example, in the 2023-2025 OPS Collective Agreement, psychology is explicitly detailed as being covered at $80 per half hour, up to $1600 per year. 

In others, the collective agreement may refer only to the payment of premiums. 

• For example, the 2018-2022 PHO Collective Agreement stipulates only that the Employer pays 100 per cent of the monthly premiums for basic dental care services, denture services, orthodontic services and major restorative services. The actual coverage rates and break-downs for these services are not provided.

Finally, in some cases, benefit plan contracts exist separately from the collective agreement, but provisions exist to incorporate that separate contract into the collective agreement. 

• For example, the 2018-2023 Waypoint Collective Agreement states that the benefits contained in the (pre-existing) Benefit Plans will be provided to full time employees and that these benefits and terms and conditions may only be altered by mutual agreement of both parties.

Arguments may arise as to which of these categories benefits language falls into, with some situations being described as “hybrid.”

Assisting a member with a benefits concern will be more clear-cut if the benefit and its coverage level are explicitly listed in the collective agreement.  

If the benefit is not explicitly mentioned in the collective agreement, you may have to do additional research, such as inquiring with an AMAPCEO staff Workplace Advisor about coverage rates and conditions in the benefit plan contract. 

Assisting members with inquiries and denial appeals 

As a Workplace Representative, you are the first point of contact for members with questions or concerns about their benefits. It is important to know the distinct process for benefit inquiries and appeals in your bargaining unit.

Inquiries

If a member comes to you with a question about their benefits and has not yet received a claims denial, you should first help them confirm that the member is correctly completing their claim submission and that the service they are inquiring about is covered under the benefit plan. 

• Use the search feature on your insurance provider’s website or app to ensure that the desired service provider is still listed and that the services they provide are covered.
• Use the search feature on your insurance provider’s website or app to look up whether a particular drug is covered under the plan, or whether a particular drug is subject to the prior authorization process.
• If there is any uncertainty as to whether a claim will be reimbursed, advise the member to get a pre-determination from your insurance provider first. This can prevent the member from incurring an out-of-pocket expense, and AMAPCEO can still appeal a pre-determination denial as if it were a claim denial.
• Determine whether Coordination of Benefits, where a member has a spouse with benefits coverage) applies to the member. In this case, if the claim is for the member, the member’s plan pays first, and the spouse’s plan would pay second. 

Denials

If a member comes to you with a claim denial or pre-determination denial, there are a number of things to confirm before appealing the denial (either to the Joint Benefits Review Committee or through the standard dispute resolution process, depending on the bargaining unit). 

• If you are in the OPS, review the Benefits Guide on the AMAPCEO website with an eye for the member’s specific issue.
• Determine if the benefit is explicitly mentioned in the Collective Agreement. If it is not, contact a Workplace Advisor to see if there are any conditions of the benefit found in the benefit plan contract.
• Ensure that the claim or pre-determination was filed within the appropriate deadlines.
  • For example, if the submission deadline is December 31 of the year after a service or item is received, and a service was rendered on March 4, 2025, then the deadline for submitting that claim would be December 31, 2026.
• Determine whether Coordination of Benefits applies and was used properly.
• Ask the member for copies of any communication with the insurance provider, including emails, notes on phone calls, decision letters, and Explanation of Benefit (EOB) documents.
• Ask the member for copies of any prescriptions required for the benefit that was denied.

Once you have completed these steps, and have confirmed with the member that they wish to pursue a claim denial appeal, you can initiate the appeal with the appropriate body. 

Claim denial appeals 

Joints Benefits Review Committees (JBRCs) are bodies which exist to hear and address benefit claim denials. They are comprised of an equal number of AMAPCEO members and employer representatives. 

Several, but not all, AMAPCEO bargaining units have JBRCs, so it is important to make sure you are addressing a member’s claim denial with the correct body. 

If your bargaining unit does not have a JBRC, appeals of claim denials are handled through the standard dispute resolution process. 

If your bargaining unit has a JBRC, you would file an appeal there. There is no strict timeline either for filing a benefit denial appeal or for how long an appeal can remain at the JBRC. JBRCs meet monthly in the OPS or as needed in other units, and work continues on cases in between meetings. 

The JBRC itself requires a member’s written consent to proceed with an appeal and involve the insurance provider. 

As a Workplace Representative, you will not have the ability to deal directly the insurance provider, as you would with an employer representative on an informal dispute about another issue.