Personal Health Insurance & Health Coverage Choice - Advisor Guide
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ContentsOverview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Selecting the right product. . . . . . . . . . . . . . . . .Products at a glance. . . . . . . . . . . . . . . . . . . . . .Plan details – Personal Health Insurance (PHI) .Plan details – Health Coverage Choice (HCC). . .Features and benefits. . . . . . . . . . . . . . . . . . . . .Prescription drugs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Drug coverage in Quebec . . . . . . . . . . . . . . . . . . . . . . . . .Supplemental health care. . . . . . . . . . . . . . . . . . . . . . . . .In-home nursing and home care. . . . . . . . . . . . . . . . . . .Paramedical practitioners. . . . . . . . . . . . . . . . . . . . . . . . . .Dental. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Vision care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Emergency travel medical. . . . . . . . . . . . . . . . . . . . . . . . .Semi-private hospital room and convalescent hospital. . 3. 5. . 7. 9. 14. 19.191919202121212122Applying for PHI or HCC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23Eligibility and issue ages. . . . . . . . . . . . . . . . . . . . . . .Renewability, expiry, convertibility – PHI and HCC. .Optional benefits – PHI and HCC. . . . . . . . . . . . . . .Premium details and rates. . . . . . . . . . . . . . . . . . . . .Grace period . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Application process . . . . . . . . . . . . . . . . . . . . . . . . . .How to apply . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23242425262627Underwriting. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29Underwriting decisions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30Post issue changes – PHI . .Post issue changes – HCC. .Right to cancel a policy. . . .Making a claim . . . . . . . . . .My Sun Life Mobile app. . . . . . . . .Web services . . . . . . . . . . . . . . . . .Paper claims. . . . . . . . . . . . . . . . . .Paying for prescription drugs. . . . .Emergency travel medical claims.General exclusions. . . . . . . . . . . . . . 31. 32. . 33. . 34.343435353637Benefit payments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38Payment of benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38Direct deposit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38Competitive advantages. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39Where to get more information. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41Personal Health Insurance& Health Coverage Choice2
OverviewSun Life offers two products that can protect Clients’ finances and help them get the care theyneed: Personal Health Insurance (PHI) and Health Coverage Choice (HCC). These products lowerthe risk of being burdened by expenses for preventive care or medical bills as a result of anillness or accident.Why have the PHI and HCC conversation with Clients?The 2013 Sun Life Canadian Health IndexTM report discovered that many Canadians expect topay nothing for health services. The reality is that provincial health plans don’t cover all medicalexpenses. This means there are gaps that can leave Clients financially devastated.Here are some examples of expenses that could have a significant impact onClients’ finances: prescription drugs treatments for a chronic or critical illness emergency medical services provided in another country nursing care provided at home medical equipment to assist with mobilityClients also want coverage to assist with the cost of services that help keep them healthy.Expenses for dental care and services such as chiropractic care, massage therapy and visioncare add up quickly. Clients who travel might also want a plan that includes emergency travelmedical coverage.When you meet with Clients, have a conversation about their current health and dentalcoverage. Do they have enough protection? Are they worried about unplanned medicalexpenses? By introducing Clients to PHI and HCC, you can help alleviate their concerns andopen the door to discussions about other health insurance needs. Customer research hasshown that Clients who already own a health insurance product are more open to consideringadditional types of health coverage.1In this guide, the symbol is used to identify a Sun Life competitive advantage. Please referto page 37 for a summary of these competitive advantages.1Source: PMG Intelligence 2013Personal Health Insurance& Health Coverage Choice3
The 2013 Sun Life Canadian Health Index report shows that many Canadians are unpreparedfor a major health event. The results reinforce the importance of talking to Clients about SunLife health insurance solutions. The study found: 38% have no group health insurance coverage, 81% have no money saved specifically for health expenses, only 21% own personal health insurance, and 1 in 5 has no group or personal insurance, and no savings to cover majorhealth expenses.This significant target market represents an opportunity to build your business.DID YOU KNOW?Each province has its own prescription drug program. Check the provincial websitewhen you’re assessing a Client’s current coverage.What is the target market for PHI and HCC?Certain Client groups are less likely to have adequate health and dental coverage or may belosing their coverage in the near future. These groups include people who are: self-employed, small business owners or employed by a small business, retired or nearing retirement, in contract or part-time positions, young individuals, couples and families, in group plans with limited coverage, or leaving or losing coverage under a group benefits plan.Personal Health Insurance& Health Coverage Choice4
Selecting the right productAfter you review the Client’s current coverage and determine they need additional coverage, howdo you help them select the product that’s right for them? Use this chart as a guide:Personal Health InsuranceMedical underwriting required.Don’t currently have adequate healthinsurance coverage or have limitations intheir current coverage.Group benefits are ending and they’re willingto go through medical underwriting.Small business owners offering this benefitto their key employees.Health Coverage ChoiceNo medical underwriting is required. Clientsare eligible if application is made within 60days of leaving a workplace or retiree healthbenefits plan.When a Client’s employment is ending,especially if they have a pre-existing medicalcondition. No eligible expenses are excludedfor pre-existing medical conditions.2Want coverage as soon as possible.Tip: Healthy Clients willing to be medicallyunderwritten may wish to consider PHI asthey can get higher coverage limits.To help a Client decide which product is best for them, discuss concerns they may have abouthealth care expenses. For example, a Client leaving a group plan with pre-existing medicalconditions may still be offered coverage for PHI with certain exclusions. A PHI Standard orEnhanced plan will give the Client some protection against catastrophic costs even thoughexpenses related to their existing conditions may not be covered.2Eligible expenses and coverage limits will be different than Clients’ previous group plan.Personal Health Insurance& Health Coverage Choice5
Case studyPaul and Lindsay are both 62. Paul is retiring at the end of the year;Lindsay retired two years ago. Their workplace or retiree health benefitsplan coverage ends when Paul retires.Paul is healthy and Lindsay manages her high blood pressure withmedication. They both have regular dental checkups and go to aregistered massage therapist periodically.They’re confident they can manage Lindsay’s existing medication costson their own, but are concerned about other medical expenses they mayencounter during retirement. So they’re working with their advisor Brian,to determine whether they should apply for additional coverage.Brian recommends they apply for PHI because it offers higher coveragelimits than HCC. They’re both approved for coverage, but due to Lindsay’shigh blood pressure, she has some exclusions. With their PHI plan inplace, they’re more confident they can continue to get the health carethey need and manage unexpected expenses during retirement.Personal Health Insurance& Health Coverage Choice6
Product at a glanceThe table below outlines the PHI and HCC products to help you determine the best plan for Clients.PHIPlan detailsHCCTypes ofplansavailable Basic plan Standard plan Enhanced plan Health and dental choice A (HCC A) Health choice B (HCC B) Health choice C (HCC C)Coverageoptionsavailable Single-person coverage for individuals Multi-person coverage for couplesor families Joint ownership not allowed Optional benefits available Plans can’t be customized Single-person coverage for individuals Multi-person coverage for couplesor families Joint ownership not allowed Optional benefits available Plans can’t be customizedIssue ages 69 or younger on the PHI application date Renewable for Clients age 70 and over 74 or younger on the HCC application date Renewable for Clients age 75 and overEligibilityrequirements Resident of Canada Covered under provincial or territorialhealth insurance Quebec residents must also have groupdrug coverage provided through an employeror through a membership in an order orassociation or, if not, through RAMQ Must be the policy owner or related tothe policy owner (see complete detailson page 24) Resident of Canada Covered under provincial or territorialhealth insurance Quebec residents must also have group drugcoverage provided through an employeror through a membership in an order orassociation or, if not, through RAMQ Have been covered under a group plan within60 days prior to the HCC application date Must be the policy owner or related to thepolicy owner (see complete detailson page 24)Renewability,expiry,convertibility Renewable for Clients age 70 and overStandalone, guaranteed renewable plansRenewable every yearNon-convertible Emergency travel medical benefit onStandard and Enhanced plans expires onthe insured person’s 80th birthday Premiumdetermined by AgePlan typeProvince of residenceAny rating for build Age Plan type Province of residenceRenewable for Clients age 75 and overStandalone, guaranteed renewable plansRenewable every yearNon-convertible Emergency travel medical benefit on HCC Band C plans expires on the insured person’s80th birthdayPersonal Health Insurance& Health Coverage Choice7
The table below is a continuation of the PHI and HCC products chart on the previous page.PHIPlan detailsUnderwritingdecisions he costs of medications, the diseaseTprocess and any pre-existing conditions aretaken into consideration.Decisions: Standard issue Modified – offer made with exclusionsbecause of pre-existing condition ortreatment. There may be a rating becauseof a person’s medical history. Declined – coverage isn’t available ifthe applicant:– is awaiting doctor-recommended testsor investigations,– has a pending surgery, or– has had certain illnesses or conditions(see the Underwriting sectionfor a partial list).Administration/ Nonepolicy feeHCC C lients must apply within 60 days ofleaving their workplace or retiree healthbenefits plan No medical evidence is required If optional dental is chosen, Clients mustalso have had dental coverage throughtheir group plan NonePersonal Health Insurance& Health Coverage Choice8
Plan details – Personal Health Insurance (PHI)Prescription drugsNow that you have a general overview of both products, it’s time to dig deeper so you can better help Clients.This table outlines the plan details for the PHI product.Basic plan 60% reimbursement 750 annual maximumExcludes oral contraceptives Up to 5 paid towards dispensingfee on prescriptionsStandard planEnhanced plan 7 0% reimbursement on first 7,000of annual eligible expenses ( 4,900paid expenses) 100% reimbursement on next 93,000 of annual eligible expenses Excludes oral contraceptives Full coverage of reasonable andcustomary dispensing fees 8 0% reimbursement on first 5,000 of annual eligible expenses( 4,000 paid expenses) 100% reimbursement onnext 245,000 of annualeligible expenses Includes oral contraceptives Full coverage of reasonable andcustomary dispensing feesAll three plans include: Pay Direct drug card for residents outside of Quebec (this card is not available in Quebec*) No deductible Smoking cessation medication ( 250 lifetime maximum) Access to my Sun Life Mobile app* F or Quebec residents, the Pay Direct drug card isn’t available. They’ll need to complete a claims form and submit it after they’ve applied for reimbursement under theirprovincial plan or group benefits plan.Personal Health Insurance& Health Coverage Choice9
Supplemental health careThis table outlines the plan supplemental health care details for the PHI product.Standard planBasic plan 60% reimbursement3 No deductible 100% reimbursement3 No deductible 100% reimbursement3 No deductibleHearing aids 400 maximum everyfive years 500 maximum everyfive years 600 maximum everyfive yearsAccidental dental 2,000 per fracture or injuryAmbulance Ground and air ambulance servicesIn-home nursing4and home care 2,500 annual maximumand a 20,000 lifetimemaximum combinedwith medical equipmentand services C ombined 5,000 annualmaximum and a combined 25,000 lifetimemaximum Combined 10,000annual maximum anda combined 30,000lifetime maximumMedicalequipmentand servicesThe following items have a 2,500 annual maximumand a 20,000 lifetimemaximum combined within-home nursing:The following items have a 5,000 annual maximum:The following items have a 5,000 annual maximum:Quebec only:Medicallynecessary MRI,ultrasounds, CATand CT scans 750 combinedannual maximum R easonable and customaryservices and charges Reasonable andcustomary services andchargesOrthopedic shoes 150 annual maximum 225 annual maximum 250 annual maximumBlood glucosemonitor 150 every five years 300 every five yearsMedicallynecessary wigsand hair pieces 100 annual maximum 500 lifetime maximumWheelchairs,walkers,traction kits 1,000 lifetime maximum 4,000 lifetime maximumHospital bed, Reasonable andcustomary servicesoxygen, continuousand chargesglucose monitor 1,500 lifetime maximum for hospital bedsSplints, crutches 500 annual maximumProstheticappliances (e.g.artificial limbs)34Enhanced plan Reasonable andcustomary servicesand charges Reasonable and customary services and charges Breast prosthesis: 200 annual maximumSee maximums listed in chart.In-home nursing includes services of registered nurses, registered practical nurses or registered nursing assistants.Personal Health Insurance& Health Coverage Choice 10
Paramedical practitionersThis table outlines the plan paramedical practitioner details for the PHI product.Basic plan 60% reimbursement 25 maximum per visit Psychologist/Social workermaximum - 35/visit up to 500/year Up to 250 per year,per type of practitionerEnhanced planStandard plan 100% reimbursement No per visit maximum Psychologist/Social workermaximum - 1000/year Up to 300 per year,per type of practitionerParamedical practitioners include: Chiropractors, including one x-ray examinationper calendar year Registered massage therapists Naturopaths and acupuncturists Osteopaths, including one x-ray examinationper calendar year 1 00% reimbursement No per visit maximum Psychologist/Social workermaximum - 1500/year Up to 400 per year,per type of practitioner Physiotherapists Podiatrists or chiropodists, including one x-rayexamination per calendar year Speech language pathologists Psychologist/Social workerNote: Clients must apply to their province of residence as first payor. The Client can submit a claim to us for the unpaid portion.Personal Health Insurance& Health Coverage Choice 11
DentalThis table outlines the plan dental details for the PHI product.Basic planPreventive 6 0% reimbursement 500 annual maximumStandard plan Optional benefit 70% reimbursement 750 annual maximumPreventive services include: Exams, diagnosis, tests, x-rays, lab exams Space maintainers for children under12 years of age Pit and fissure sealant for children under19 years of ageEnhanced plan O ptional benefit 80% reimbursement 750 annual maximum A three month waiting period beforecoverage begins White fillings Scaling, minor extractions Nine month recall visitsRestorative No coverage No coverage Orthodontics No coverage No coverage Optional benefit50% reimbursement 500 annual maximum One year waiting periodbefore coverage begins Includes endodontics,periodontics, oral surgery,crowns, onlays, bridges,dentures (and repairs) Optional benefit60% reimbursement 1,500 lifetime maximum Two year waiting periodbefore coverage beginsVision careThis table outlines the plan vision care details for the PHI product.Basic plan No coverageStandard planEnhanced plan 100% reimbursement 250 maximum every two years ( 300 maximum every two years forEnhanced), including 50 maximum per eye exam One year waiting period before coverage begins Prescription eye glasses, contact lenses, sunglasses and laser eye surgeryPersonal Health Insurance& Health Coverage Choice 12
Emergency travel medicalThis table outlines the plan emergency travel medical details for the PHI product.Standard planBasic plan No coverage Enhanced plan100% reimbursement 1 million lifetime maximumCoverage provided for the first 60 days of a tripCovers travel outside of the Client’s province and outside of CanadaMultiple trips allowedCoverage ends on the insured person’s 80th birthday. If the Client has a pre-existing medical condition where symptoms haveappeared or required medical attention, hospitalization or treatment (thisincludes changes in medication or dosage), and existed during the ninemonths before their trip, expenses related to this condition aren’t includedSemi-private hospital roomThis table outlines the plan semi-private hospital room details for the PHI product.Basic planStandard planEnhanced planConsider adding the optional benefit of a semi-private hospital room to any of the three plans.This will provide you with: 85% reimbursement Coverage up to 200 daily and 5,000 annually Convalescent hospital: 20 per day, up to 180 days per incidentNote: Premiums for PHI plans are reviewed each year and may change. We give the policy owner 30 days’ notice if premiums are changing. The change is based on theexperience of an entire age group within a plan series; it’ll never change for a single individual based on their personal experience.Personal Health Insurance& Health Coverage Choice 13
Plan details – Health Coverage Choice (HCC)Prescription drugsReview the table below for details on the HCC product.Health and dental choice A 80% reimbursement 500 annual maximum Up to 5 paid towards dispensingfee on prescriptionsHealth choice B 80% reimbursement 1,300 annual maximum Full coverage of reasonable andcustomary dispensing feesHealth choice C 8 0% reimbursement 2,600 annual maximum Full coverage of reasonable andcustomary dispensing feesAll three plans include: Pay Direct drug card for residents outside of Quebec (this card is not available in Quebec*) No deductible Smoking cessation medication ( 250 lifetime maximum) Access to my Sun Life mobile app* F or Quebec residents, the Pay Direct drug card isn’t available. They’ll need to complete a claims form and submit it after they’ve applied for reimbursementunder their provincial plan or group benefits plan.Personal Health Insurance& Health Coverage Choice 14
Supplemental health careThis table outlines the plan supplemental health care details for the HCC product.Health anddental choice AHealth choice B 80% reimbursement5 100% reimbursement5 100% reimbursement5Hearing aids 300 maximum everyfive years 400 maximum everyfive years 600 maximum everyfive yearsAccidental dental 2,000 per fractureor injury 5,000 lifetime maximumAmbulance Ground ambulance services No coverage for air ambulance6 A ir ambulance 5,000maximum per incidentIn-home nursing6and home care 2,500 annual maximumand a 20,000 lifetimemaximum combinedwith medical equipmentand services 5,000 annual maximum and a 25,000lifetime maximumMedicalequipmentand servicesThe following items have a 2,500 annual maximumand a 20,000 lifetimemaximum combined within-home nursing:The following items havea combined 2,500annual maximum:The following items havea combined 5,000annual maximum:Quebec only: No coverageMedically necessaryMRI, ultrasounds,CAT and CT scans R easonable and customaryservices and charges R easonable and customaryservices and chargesOrthopedic shoes 200 annual maximum 250 annual maximumBlood glucosemonitor 150 every five years 250 every five years 300 every five yearsMedicallynecessary wigsand hair pieces 100 annual maximum 350 lifetime maximum 500 lifetime maximumWheelchairs,walkers,traction kits 1,000 lifetime maximum 4,000 lifetime maximumHospital bed, Reasonable andcustomary servicesoxygen, continuousand chargesglucose monitor 1,500 lifetime maximum for hospital bedsSplints, crutches 300 annual maximumProstheticappliances (e.g.artificial limbs)5Health choice C Reasonable andcustomary servicesand charges 500 annual maximum Reasonable and customary services and charges Breast prosthesis: 200 annual maximumSee maximums listed in chart.In-home nursing includes services of registered nurses, registered practical nurses or registered nursing assistants.Personal Health Insurance& Health Coverage Choice 15
Paramedical practitionersThis table outlines the plan paramedical practitioner details for the HCC product.Health and dental choice A 80% reimbursement 25 maximum per visit Up to 250 annually per type ofpractitioner, except psychologists Psychologist/Social worker – 60/visit up to maximum 300 annuallyHealth choice B 100% reimbursement No per visit maximum 300 per year, per type ofpractitioner and combinedmaximum up to 500 percalendar year Psychologist/Social worker – 70/visit up to seven visitsParamedical practitioners include: Chiropractors, including one x-ray examination percalendar year Registered massage therapists Naturopaths and acupuncturists Osteopaths, including one x-ray examination percalendar yearHealth choice C 100% reimbursement No per visit maximum 300 per year, per type ofpractitioner and combinedmaximum up to 650 percalendar year Psychologist/Social worker – 75/visit up to 10 visits Physiotherapists Podiatrists or chiropodists, including one x-rayexamination per calendar year Speech language pathologistsNote: We may change rates each year. If we do change the rates, we’ll send the policy owner written notice 30 days before the change.Vision careThis table outlines the plan vision care details for the HCC product.Health and dental choice AHealth choice BHealth choice CAll three plans include: 100% reimbursement 150 maximum every two years ( 200 maximum every two years for Health choice B or 300 maximumevery two years for Health choice C), including 50 maximum per eye exam Coverage of prescription eyewear, contact lenses, prescription sunglasses and laser eye surgeryPersonal Health Insurance& Health Coverage Choice 16
Emergency travel medicalThis table outlines the plan emergency travel medical details for the HCC product.Health choice BHealth and dental choice A No coverage Health choice C100% reimbursement 1 million lifetime maximumCoverage provided for the first 60 days of a tripCovers travel outside of the Client’s province and outside of CanadaMultiple trips allowedCoverage ends on the insured person’s 80th birthday If a Client has a pre-existing medical condition where symptoms haveappeared or required medical attention, hospitalization or treatment (thisincludes changes in medication or dosage), and existed during the ninemonths before their trip, expenses related to this condition aren’t includedSemi-private hospital roomThis table outlines the plan semi-private hospital room details for the HCC product.Health and dental choice A 50% reimbursement 5,000 annual maximumHealth choice B 175 daily maximumHealth choice C 200 daily maximum 85% reimbursement 5,000 annual maximum Convalescent hospital: 20 per day, up to 180 days per incidentEligible expense limitsThis table outlines the plan Eligible expense limits details for the HCC product.Health and dental choice A 250,000 lifetime maximum77Health choice BHealth choice C 300,000 lifetime maximum7Lifetime maximum applies to drug, supplemental health care, paramedical practitioners, vision and semi-private hospital room.Personal Health Insurance& Health Coverage Choice 17
DentalClients may also want dental coverage. Review the dental options in this table and help Clients pick the choice thatmeets their needs.Note: Dental coverage is an optional benefit. To be eligible for dental coverage, everyone on the application musthave had dental coverage through the Client’s group benefits plan. Preventive and major restorative dental coverageare optional benefits you can offer Clients to add to Health choice B or C.Health choice BHealth and dental choice APreventive I ncluded 80% reimbursement 700 annual maximum Optional benefit 80% reimbursement 700 annual maximumcombined with restorativePreventive services include: Examinations and diagnosis Tests, x-rays and lab exams White fillings Space maintainers for children under12 years of ageRestorative No coverageHealth choice C Optional Benefit 80% reimbursement Year 1: 750annual maximum Year 2 : 1,000 annualmaximum combinedwith restorative Scaling and extractions Pit and fissure sealant for children under19 years of age Recall visits every nine months Minor emergency treatments Optional Benefit 50% reimbursement 700 annual maximumcombined with preventive One year waiting periodbefore coverage begins estorative services include:R Endodontics Periodontics Oral surgery Crowns Optional Benefit50% reimbursementYear 1: No coverage Year 2 : 1,000 annualmaximum combinedwith preventive One year waiting periodbefore coverage begins Onlays Bridges Dentures (and repairs)Personal Health Insurance& Health Coverage Choice 18
Features and benefitsTIP! We’ll point out the different HCC plan levels through the guide using theseshort forms:HCC A Health and dental choice AHCC B Health choice BHCC C Health choice CPrescription drugsMany Clients are concerned about paying for prescription drugs. These costs can add up overtime and be catastrophic when dealing with a serious or chronic illness. PHI and HCC plansoffer different levels of prescription drug coverage, including catastrophic drug coverage on PHIStandard and Enhanced plans.For example, a person with eligible drug expenses of 20,000 in one year would be reimbursedat 17,900 under a PHI Standard plan. Under a PHI Enhanced Plan, that person could expect 19,000 to be reimbursed.Where available, Clients must first submit drug coverage claims to their provincial plan. Anyeligible unpaid claims can then be submitted to Sun Life. A formulary is the list of drugs coveredby a drug plan. Some prescribed drugs may not be on the provincial formulary but may becovered by the more extensive PHI or HCC formulary.The drug formularies for PHI and HCC include both generic and brand name drugs. Clients canuse the my Sun Life Mobile app to learn about a drug and potential generic or therapeutic
Life health insurance solutions . The study found: 38% have no group health insurance coverage, 81% have no money saved specifically for health expenses, only 21% own personal health insurance, and 1 in 5 has no group or personal insurance, and no savings to cover major health expenses .
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