Reserve Dental Care Plan Administrative Instructions

Section 1: About the Reserve Dental Care Plan and the Administrative Instruction Manual

1. Overview

Section 1 deals with the Reserve Dental Care Plan (RDCP) and the administrative instruction manual for Orderly Room clerks. Definitions for the manual are included within the description and purpose.

2. Reserve Dental Care Plan Administrative Instructions: Description and Purpose

This administrative instruction manual functions as a reference guide to the RDCP.

Primary audience

This instruction is for Orderly Room staff involved in administrating dental claims for Reserve Force members.

Purpose of administrative instructions

The objective of this manual is to provide Orderly Room clerks, who administer RDCP dental claims, with accurate direction and easily accessible information. Providing procedures, which are consistently applied to all the Reserve Units, will result in a significant decrease to the numbers of erroneously completed dental claims and facilitate the administration of RDCP claims.

Layout of the manual

This manual has been designed so users may easily navigate through the sections and retrieve information. This manual has been divided into five general areas. Heading each section is an overview page that refers the reader to relevant and specific topics contained within each general section.

Definitions - For purposes of this instruction manual:

55999

group policy or plan number for the Reserve Dental Care Plan (RDCP);

55777

group policy or plan number for the Dependants' Dental Care Plan (DDCP);

Canadian Forces (CF) Dental Care Plan Board

the Board established to oversee the administration of the CF Reserve Dental Care Plan;

Canadian Forces (CF) Dependants' Dental Care Plan

the Plan introduced on 1 October, 1987 for the dependants of Regular and Class C Reserve Force members;

dentist

a person licensed to practice dentistry by the appropriate governmental licensing authority, provided that such a person renders a service within the scope of his or her license;

dependant coverage

coverage for either an eligible child or an eligible spouse;

eligible child

the person who is an unmarried child of a member or of the member's spouse or common-law partner, including an adopted child, a step-child, a foster child or legal guardian, in respect of whom the member stands in loco parentis (*), provided such person is:

under twenty-one (21) years of age, or

twenty-one (21) years of age or over who is incapable of engaging in self-sustaining employment by reason of mental or physical impairment, and is primarily dependant upon the member for support and maintenance, provided the child;

is a person to whom the above description applies on the date the member becomes eligible to obtain coverage, or

was disabled under this plan immediately prior to his or her twenty-first birthday or between the ages of 21 and 25, provided he or she is a student on a full-time basis;

between twenty-one (21) and twenty-five (25) years of age and in full-time attendance at an educational institution

who is not covered as a member/employee of any component of the Public Service Dental Care Plan;

(*) this needs to be approved by the Board on a case basis.

eligible spouse

for purposes of this manual, the person legally married to the member, or a person with whom the member is in a common-law relationship, or a person from whom the member is separated.

eligible member

a member who satisfies the definition and who meets the eligibility criteria to participate in the Reserve Dental Care Plan;

member

an officer or non-commissioned member of the CF Regular Force or of the Reserve Force;

parent unit

the Unit on whose establishment the member is carried;

place of Reserve employment

or employing unit means the place (or unit) of actual employment, which may or may not be the parent unit;

plan

the Reserve Dental Care Plan;

plan administrator

the insurance company selected to execute certain administrative functions required for the operation of the Plan, currently The Great-West Life Assurance Company;

PRes Health Benefits Stamp

the Primary Reserve Health Benefits Approval Stamp;

Public Service Dental Care Plan

a dental services plan for the benefit of eligible federal Public Service employees and employees of a number of designated agencies. Other components of this plan are the Canadian Forces Dependants, the Canadian Forces Reserve, the Royal Canadian Mounted Police Dependants, the Public Service Alliance of Canada, and the National Joint Council;

unit

all HQ's, Reserve and Regular Force Units, Detachments, Primary Reserve Lists, Ranger Patrol Groups, Regional Cadet Support Units and units that administer the Supplementary Ready Reserve.

3. The Reserve Dental Care Plan

Authority

The Treasury Board of Canada Secretariat (TBS) established the Public Service Dental Care Plan (PSDCP). The complete terms and conditions of this component of the Dental Care Plan (DCP) are contained in the Rules of the Canadian Forces/Royal Canadian Mounted Police/Canadian Security Intelligence Service Dental Care Plan.

About the Plan

The Canadian Forces Reserve have had dental coverage provided through the PSDCP for Reserve Force members and their dependants since 1 January 1991.

This Plan provides members of the Reserves or their eligible dependants, as applicable, with coverage for specific dental services or supplies, as set out in the Plan rules (Section 4).

TBS

The RDCP is one component of the Public Service Dental Care Plan. The Plan is voluntary and entirely paid for by the Government of Canada. TBS establishes the rules and terms of the Plan.

Plan Administrator

The Great-West Life Assurance Company is the Plan Administrator for all the components of the PSDCP. For contact information, refer to Section 4.

Plan Office of Primary Interest (OPI)

National Defence Headquarters (NDHQ) - Director of Pensions and Social Programs (DPSP).

Other sources of information

Other sources of information for the CF Dental Care Plans are:

• CF Dental Care Plan Booklet
• Health and Dental web page
• TBS website
• Clerk's Aid Sheet - Determining Eligibility, Annex C
• Clerk's Aid Sheet - Stamping the Claim, Annex D
• Member's Aid Leaflet - Completing RDCP Claim Form, Annex E

4. Roles and Responsibilities

Five parties are involved in the administration of the Reserve Dental Care Plan:

• TBS;
• Plan Administrator (Great-West Life);
• National Defence Headquarters (NDHQ) - Directorate of Pensions and Social Programs;
• Unit Orderly Room; and
• the member employed on Reserve service.

Each has specific roles and responsibilities that are detailed below.

TBS

• provides the Rules and the terms of the Plan and oversees the administration by The Great-West Life Assurance Company and the Department of National Defence;
• pays the cost of the Plan, manages the Plan and monitors its financial performance and its administration; and
• approves the Rules, provides policy interpretation and issues Plan directives.

Plan Administrator

As the Administrator, The Great-West Life Assurance Company:

• adjudicates claims and issues benefit payments to members;
• answers inquiries related to claims or services covered under the Plan;
• reports administrative or individual problems to NDHQ or Treasury Board of Canada Secretariat; and
• provides regular reports on the performance of the Plan.

DPSP

The Director of Pensions and Social Programs is the OPI and is responsible for:

• preparing manuals, internal administrative instructions, plan member booklets and information notices for members;
• advising unit clerks;
• verifying member eligibility in response to requests from Plan Administrator; and
• investigating and resolving problems reported by the Plan Administrator.

The Board

The Board is responsible for:

• resolving members' disagreements with the decisions of the Plan Administrator;
• resolving issues of member eligibility; and
• making recommendations from time to time on the Plan to the Chief of Defence Staff and to the Treasury Board Secretariat of Canada.

Reserve Units

Reserve Unit Orderly Room clerks are responsible for:

• maintaining accurate records (including: member's Personnel File - copies of claims, periods of service and amendments to periods of service);
• verifying eligibility;
• issuing Plan Certificate numbers;
• maintaining a Log of Certificate numbers issued;
• ensuring claim forms are properly completed;
• stamping claim forms;
• counseling Reservists on the Dental Care Plan;
• ensuring that PRes Health Benefits Stamp is used correctly and secured;
• updating member's files;
• providing Dental Plan information to new Reservists;
• announcing Plan changes issued by NDHQ (e.g. updates to annual maximum); and
• contacting parent units, where a member's employing unit is not their parent unit, to ensure member's eligibility to participate in the Plan.

Member

The member is responsible for:

• knowing Plan provisions;
• retaining and using the certificate number issued initially;
• accurately completing the dental claim form; and
• submitting dental claims to the Unit Orderly Room.

Section 2: RDCP Plan Participation

1. Overview

Section 2 outlines participation in the RDCP. The objective is to inform the Orderly Room clerks of all areas pertaining to participation in the RDCP, such as:

• verifying that the member meets the eligibility criteria to participate in the Plan, as set out by the Plan provisions;
• establishing effective coverage commencement and cease dates and advising the member;
• ascertaining how changing class/length of Reserve employment will affect the member's eligibility and coverage commencement and termination dates;
• advising annuitants, who are required to take a 35 day break, with respect to their RDCP eligibility and coverage during the break; and
• understanding the importance of the PRes Health Benefits Stamp; Certificate Numbers; and the Certificate Numbers Log.

2. Who is Eligible to Participate in the Reserve Dental Care Plan?

Without a centralized database to manage Reserve participation in the RDCP, Great-West Life is unable to precisely determine the eligibility of Reserve Force members for the RDCP. As a result, the Unit Orderly Room is responsible for determining whether the member is entitled to participate in the Plan.

3 Month service requirement

Before becoming eligible under the RDCP, the member must have completed 3 months of continuous service in either the Regular Force or the Reserve Force. This is a one-time requirement.

Eligibility criteria

To determine a member's eligibility, the Unit Orderly Room must ensure that the member meets the following criteria before claims may be submitted:

• the member is in good standing; and
• the member does not have other dental insurance coverage, where the member is listed as the member/employee of another insurance plan; and
• the member's class and length of Reserve employment designates the member eligible to participate in the RDCP; and
• member is not covered under a parent's plan that is a component of the Public Service Dental Care Plan. These are described in detail below.

Annuitants on 35-day break

During the mandatory break(s) in service, annuitants do not meet the eligibility criteria as mentioned above.

Good standing

The term in good standing means a member of the Primary Reserve who:

• is serving on Class B service; or
• attends at least one Class A parade per calendar month* ; or
• is granted ED&T (Exempt Drill & Training) by a commanding officer or higher authority; or
• is held on either the NDHQ or a Command Primary Reserve List (PRL).

*If the member does not meet the Class A parade requirement due to extenuating circumstances, the Unit Orderly Room may still deem them to be in good standing, (e.g. civilian occupational requirement, University exams).

Member / employee of another insurance plan

A member, who is covered as a dependant under a spouse's plan, remains eligible to participate in the RDCP. However, where the individual is entitled to benefits as a member/employee under another insurance plan, the member becomes ineligible to participate in the Reserve Dental Care Plan.

Class/length of service and eligibility

Members of the Primary Reserves on:

• Class A service may cover themselves only.
• Class B service (180 days or less) may cover themselves only.
• Class B service (181 days or more) may only cover their dependants (i.e. eligible child and/or eligible spouse).
• Class B service: CIC, Supp Res or Cdn Rgr(S) (181 days or more) may only cover their dependants (i.e. eligible child and/or eligible spouse).
• Class C Reservists are not entitled to participate in the RDCP. Instead, they may cover their dependants under another component of the CF Dental Care Plan: the Dependants Dental Care Plan (policy #55777).

NOTE: CIC, Supp Res, and Cdn Rgr(S) on Class A or short-term Class B are not eligible to participate in the RDCP.

Member is not covered under a parent's plan

Once a member is eligible in his/her own right to participate in the RDCP, they are no longer eligible for coverage through a parent who is a participant in any component of the Public Service Dental Care Plan.

Substantiating eligibility

Route Letters shall not be used to substantiate a member's class or length of service. For purposes of determining member's eligibility, Orderly Rooms are instructed to use the member's most current message, taking into account all applicable amendments. *

* A copy of the member's most current period of service message, or amendments to period of service message should be kept on the member's Personnel File.

3. Effective Coverage Commencement and Cease Dates

For the most part, membership in the Plan is effective the first day of the member's period of employment on Reserve service, and is terminated effective the last day of the member's period of employment on Reserve service. This does not apply for all situations, therefore refer to the guide below to accurately determine coverage start and cease dates for a member.

Role of the Unit Orderly Room

The Unit Orderly Room is responsible for validating a member's dental claim and the Unit must ascertain that the member's class and length of Reserve employment (Section 2) accurately qualifies the member to participate in the Reserve Dental Care Plan.

Examples

The following table illustrates effective coverage commencement dates:

Coverage cease date

Coverage for members on Class A or B (180 days or less) service, who have member coverage only, membership in the Plan ends automatically on the last day of the member's period of service.

Coverage for members on Class B (181 days or more), who have dependant coverage only, membership in the Plan ends:

• When the member's spouse ceases to be an eligible spouse; or
• On the last day of the member's period of service; or
• When the child(ren) ceases to be an eligible child (e.g. child reaches 21 years of age, or 25 years of age if in full-time attendance at school or university), or on the last day of the member's period of service.

Extended benefits: extensive dental treatment or orthodontic services

The following benefits may be extended beyond the last day of the member's period of employment:

Orthodontic services

Where the initial appliance was inserted prior to termination for a member or an entitled spouse/child before the child attained the age of twenty-one or twenty-five. In the case of a student, ongoing orthodontic treatment will be covered for 31 days. This includes the month of termination or the month of the child's twenty-first or twenty-fifth birthday.

Extensive Dental Treatment

An extensive dental procedure (such as a Root Canal Treatment, Placement of a Bridge, Crown or Dentures), which began prior to the date of a member's service termination date, will be eligible for coverage only if it is completed within 31 calendar days of the member's termination of service date.

Extensions or shortened periods of service

Coverage commencement and cease dates may be affected resulting from changes to a member's class/length of service. Refer to Section 2.

Substantiating coverage start/cease dates

Route Letters shall not be used to substantiate a member's class or length of service. For purposes of determining effective coverage start and cease dates, Orderly Rooms are instructed to use the member's most current message, taking into account all applicable amendments.

4. Changing Class/Length of Reserve Service and How it Affects Plan Participation

Changing class/length of Reserve service may result in changes to who is covered under the RDCP, the Plan policy number and/or the member's identification number.

Role of the Unit Orderly Room

The Unit Orderly Room's role is to determine whether a change in class/length of Reserve employment alters the member's:

• Eligibility to participate in the RDCP; or
• Coverage under the RDCP.

See examples below.

Examples

The following table outlines examples which reflect coverage, policy number and identification number for the different classifications of Reserve service:

Extended service (beyond 181 days)

Where a period of Class B service (180 days or less) has been extended beyond 180 days, the member becomes eligible to participate in the RDCP for dependants only (i.e eligible child/spouse), effective the date of the message authorizing the new period of service.

The member becomes entitled to dental coverage from CF Dental Services, effective the same date.

Shortened period of service

A member's coverage is affected when the member's period of Class B service (181 days or more) has been shortened to a period of less than 180 days. The member becomes entitled to coverage for himself or herself only under the Reserve Dental Care Plan, as the member ceases to be entitled to dental coverage from CF Dental Services, effective the date of the message authorizing the new period of service.

Examples: From Class A/B to Class C (and vice-versa)

• A member on Class A/B who proceeds to Class C becomes ineligible to claim under the Reserve Dental Care Plan (effective the last day of Class A/B service). The member shall report to the Orderly Room (employing unit) to effect a start date in the Dependants' Dental Care Plan. The member shall keep their certificate number should the member revert to Class A/B and resume their coverage in the RDCP.
• A member on Class C who proceeds to Class A/B becomes ineligible to participate in the Dependants' Dental Care Plan (effective the day following the last day of Class C service) and may participate in the RDCP. If the member had previous coverage in the RDCP, the member shall use the same certificate number.
• Refer to the table in the Examples table above.

One certificate number per member

Once a member has participated in the RDCP and has been assigned a certificate number, that member shall retain the certificate number issued for the duration of Reserve service, regardless of class/length of employment, transfers or release.

Substantiating class/length of service

Route Letters shall not be used to substantiate a member's class or length of service. For purposes of determining a member's eligibility, Orderly Rooms are instructed to use the member's most current message (s), taking into account all applicable amendments. *

* A copy of the member's most current period of service message, or amendments to period of service message should be kept on the member's Pers File.

5. Annuitants and the 35-Day Break

Annuitants employed on Class B (181 days or more) and Class C Reserve service are subject to mandatory breaks in service. This outlines how such breaks affect the member's dental coverage.

Eligibility for the RDCP

Members on mandatory break(s) in service are not eligible to participate in the CF Dental Care Plans.

RDCP coverage cease and re-commencement

Coverage ceases on the last day of the service before the break and re-commences on the first day of a member's return.

During the break(s), members will be responsible for their own dental expenses.

Exceptions are possible for orthodontics and certain treatments begun while the member was serving (e.g. root canals), but these are rare. Refer to the CF Dental Care Plan Booklet for details.

Informing the member

There are three possible scenarios for dental care coverage for CF Annuitants during their break(s) in service:

* Coverage under the PDSP is only available to an eligible pensioner, who initially deferred PDSP coverage, and who elects to activate coverage under the PDSP during the break.

Scenario #3

The following table provides more information on Scenario #3 from the table above:

Roles and responsibilities

DPSP is the OPI for the CF Dental Care Plans. The CF Dental Care Plans are comprised of the Dependants Dental Care Plan and the Reserve Dental Care Plan. The Great-West Life Assurance Company of Canada administers these plans.

The Treasury Board of Canada Secretariat is the OPI for the Pensioners' Dental Services Plan (PDSP), which is administered by Sun Life Assurance Company of Canada. It has separate rules and provisions from the CF Dental Plans.

Reference

Refer to Annex G for a copy of the release referent to Annuitants and the mandatory break.

6. The PRes Health Benefits Stamp

Dental claims may not be submitted electronically from the dentist's office. Members must process their claims through the Orderly Room clerk for verification. The PRes Health Benefits Stamp is used to substantiate that the member has met the required eligibility criteria to participate in the Plan. The stamp conveys to the Plan Administrator that the eligibility criteria has been met and the claim has been accurately completed. *

*NOTE: The PRes Health Benefits stamp is the only stamp that is acceptable for substantiating claims. Without this stamp, dental claim forms will not be processed by the Administrator and will be returned to the member.

Security

The PRes Health Benefits Stamp is a Protected B item and, as such:

• shall be handled in accordance with National Defence Security Instructions (NDSI); and
• shall be locked away when not in use; and
• access to the stamp is for authorized personnel only.

Purpose and importance of the PRes stamp

The stamp is applied to the member's claim to establish (to the Plan Administrator) that the member has met the eligibility criteria outlined at Section 2 and that the Orderly Room Clerk has substantiated the claim (refer below).

Without the stamp, the Administrator will not process the dental claim and will return the claim to the member.

Substantiating claims

The stamp is used to substantiate:

• that the claim has the appropriate Plan policy number and member's certificate number (Identification number);
• that the claim is for an eligible person, which corresponds with the member's Class/length of service (Section 2). Example: A member on long-term Class B and claiming an eligible dependant or a member on Class A or short-term B and claiming for self.
• that the member is not entitled to benefits as a member /employee under another insurance plan, where the member indicated (Part 2: Section 5 of the CF Reserve Class A and B Service Dental Care Plan Claim Form at Annex A) that the member or any dependant(s) is/are entitled to benefits as a member/employee under this Plan or any other group plan.

Stamp parts table

When the sections on the stamp are completed by the parent/employing unit, Great-West Life will consider the claim to be complete.

If this information is not entered in the stamp, the claim will be returned.

When to use the stamp

The PRes Health Benefits stamp is to be used after:

• the clerk has reviewed the dental claim and substantiated the information, as outlined in 'substantiating claims'; and
• the member has been determined to be eligible to participate in RDCP for either member only coverage, or dependant only coverage.

Obtaining a stamp

Stamps may only be obtained from the OPI, by preparing a written request.

Reg Force unit requesting a PRes Health Benefits stamp

Occasionally, a Reg Force unit employing Reserve Force members will want to obtain a PRes Health Benefits stamp. The following information shall be included in the written request:

• reason for requesting a stamp;
• the number of Reservists employed at the Unit;
• duration of the employment period; and
• the recurrence of this employment (i.e. four months per year for five years).

7. Certificate Numbers

Without a current centralized database for the Primary Reserve, the Plan Administrator (Great-West Life) is unable to maintain an accurate record of who has enrolled in the RDCP. By providing units with certificate numbers, member participation may be more precisely controlled.

Certificate numbers

• The Unit Orderly Room will assign certificate numbers only to members who are eligible for this Plan, taken in sequence from the list supplied by the OPI.
• These numbers are not related to SIN or Service Numbers and are to be assigned on a first come, first served basis, therefore, service numbers cannot be used.
• The certificate number serves as the member's Plan identification number for the duration of the member's Reserve service. Only one certificate number shall be issued per member.

Obtaining blocks of certificate numbers

• Blocks of numbers and instructions were issued to each Command/Reserve HQ, (Ref: 1150-1 (DGRC) 16 January 1991).
• Units shall contact the Reserve Dental Care Plan OPI for the assignment of additional blocks of numbers.

When is the member's certificate # registered with administrator?

When a member is assigned a first certificate number and submits the first claim, the member is not registered as a participant in the Plan until the first claim is processed. Once processed, the member will be added to the Plan Administrator's system.

Examples of certificate numbers

Certificate numbers will have a total of nine (9) characters consisting of three letters and six numbers. The letters will provide a distinctive designator, showing which command the member belongs to. Numbers will resemble the following examples:

• AIR-000-010 (Air Reserve assigned number)
• COM-000-010 (Communication Reserve assigned number)
• MIL-000-010 (Militia assigned number)
• NAV-000-010 (Naval reserve assigned number)
• PRL-000-010 (NDHQ or Command PRL assigned number)
• RGR-000-010 (Canadian Rangers assigned number)
• CIC-000-010 (Cadet Instructor Cadre assigned number)

Maintaining certificate number when member transfers

• A Reservist who transfers between Commands, transfers to the Regular Force and subsequently returns to the Reserve, or releases and enrols again in the Reserve shall retain the certificate number that was initially assigned and carry that number to the new Command.
• The losing Unit is responsible for advising the gaining Unit of any previously assigned certificate number. This should be included in member's Pers File.
• New employing units should check with former unit(s) for any previously assigned certificate number.

Re-issuing the same certificate number

Certificate numbers for members who have released from the CF, shall not be re-assigned.

More than two numbers assigned

Where the member submits a claim and Great-West Life locates two or more certificate numbers assigned to that member, the Administrator will return the claim to the member. The member shall complete the claim form again, using the first certificate number assigned under the RDCP. The OR clerk may re-issue the other number(s), keeping a record in the Certificate Numbers Log.

8. The Certificate Number Log

The Unit Orderly Room clerk shall keep a certificate log to track all phases of certificate number assignment: from assignment to the Unit; to issuing them to the members; to maintaining them once they have been assigned.

Purpose of maintaining a Certificate Number Log

It is important for the parent/employing unit to maintain a Certificate Number Log. This log will:

• assure the maintenance of an accurate record of previously assigned certificate numbers;
• record the numbers available for issue, thereby creating an accurate account of Reserve members who are participating in the Reserve Dental Care Plan; and
• identify members who have left the Unit (release, transfer etc.) and members who have transferred/ been posted into the Unit with previously assigned certificate numbers.

Security

The Certificate Number Log is a Protected A document. Access to it shall be by authorized personnel only.

Sample log

The following is an example of a Certi ficate Number Log:

Section 3: Dental Claims

1. Overview

Section 3 provides information and procedures for the Unit Orderly Room clerk that are related to the processing of claims. This Section includes key information that the clerk can communicate to the member. It is the responsibility of the Orderly Room clerk to:

• review the member's dental claim;
• certify that the member has met the eligibility criteria to participate in the Plan; and
• stamp the claim to substantiate that the member is entitled to the benefits under the RDCP.

2. Determining Eligibility

After a dental claim form has been submitted to the Unit Orderly Room, the Orderly Room clerk must validate that the member has met the eligibility criteria to participate in the RDCP (refer to Section 2), and that the claim has been completed accurately. The following describes a procedure that the OR clerk may implement when establishing whether a member is entitled to participate in the Plan.

Purpose of the procedure

The purpose of including this procedure is to:

• emphasize to Orderly Room clerks the importance of their role in substantiating that the member has met the eligibility criteria to participate in the Plan; and
• communicate to the clerk the significance that reviewing and substantiating claims has in the process of administrating dental claims; and
• facilitate the task of administering dental claims for all clerks new to their positions in the Orderly Room.

Procedure

The following reflects the procedure that an Orderly Room clerk may practice when substantiating whether or not the member is eligible to participate in the Reserve Dental Care Plan (RDCP). Refer to Annex D.

• Step 1 - Member requests to enrol in the Reserve Dental Care Plan (RDCP).
• Step 2 - Determine whether member has served the 3-month service requirement (Refer to Section 2).
  • If the member has completed the 3-month service requirement, then go to Step 3.
  • If the member has not completed the 3-month service requirement, then the member is not yet eligible to particiapte in the RDCP.
• Step 3 - Determine the member's eligibility, with respect to the criteria detailed at Section 2.
  • If the member is a PRes on Class A or B service; or is a Class B CIC, Supp Res, or Cdn Rgr (181 days or more); and is in good standing, then go to Step 4.
  • If the member does not meet the criteria mentioned above, then the member is ineligible to participate in the Reserve Dental Care Plan Note: Annuitants on mandatory 35-day break do not meet the eligibility criteria.
• Step 4 - Determine whether the member is entitled to benefits as a member/employee of another insurance plan. Refer to Section 2.
  • If the member is entitled to benefits as a member/employee or of another insurance plan, then the member is ineligible to participate in the Reserve Dental Care Plan.
  • If the member is covered as a dependant under spouse's plan, then go to Step 5.
  • If the member is covered as a dependant under a parent's plan, where parent is a participant in the Public Service Dental Care Plan or one of its components, then the member is ineligible to participate in the Reserve Dental Care Plan.
• Step 5 - Verify whether the member has previously been assigned a certificate number by asking the member or verifying it with member's former unit(s). Note: The Certificate Number initially assigned to a member is retained for life, even if the member transfers to another Unit, Element or Component.
  • If the member has previously been assigned a certificate number, then member retains first assigned certificate number, and a new number is not issued.
  • If the member has never been assigned a certificate number, then assign a certificate number to the member from the certificate log. Make note in member's Pers File . Go to Step 6.
• Step 6 - Where a claim is for dependants, verify that the dependant is an eligible child and/or an eligible spouse.
  • If the member is submitting a claim for a common-law partner, then the Orderly Room clerk shall ensure that the relationship has been officially recognized IAW QR&O 1.075.
  • If the member is submitting a claim for a child, then the Orderly Room clerk shall ensure that a birth certificate is on the member's Pers File.
  • If the member is submitting a claim for an adopted child, then the Orderly Room clerk shall ensure that adoption papers are on the member's Pers File.
  • If the member is submitting a claim for or a child for whom the member stands in loco parentis, e.g. legal guardian, then the Orderly Room clerk shall ensure that member must refer to OPI for Board approval.
• Step 7 - Stamp the claim using the PRes Health Benefits stamp.
• Step 8 - Keep a copy of each claim on the member's Pers File for future reference.

Registration as a participant

A member is not registered as a participant in the Plan until the first claim is processed and added to the Plan Administrator's system.

3. Stamping the Claim

The Plan Administrator looks for the PRes Health Benefits stamp when in receipt of a Reserve Dental Care Plan claim. If the stamp does not appear on the claim form, Great-West Life will return the claim to the member. The following procedure shall be implemented prior to sending the claim to the Plan Administrator.

Significance of PRes Health Benefits stamp

For the Plan Administrator, the PRes Health Benefits Stamp substantiates that the Orderly Room has verified that:

• the member meets the eligibility criteria qualifying the member to participate in the Plan;
• the claim has been completed and signed by the member; and
• the clerk has substantiated the claim form.

Without this stamp, dental claim forms will not be processed by the Administrator and will be returned to the member.

The PRes Health Benefits stamp

For information on the PRes Health Benefits stamp, refer to Section 2. The Pres Health Benefits Stamp is the only stamp that is acceptable when substantiating claims.

Procedure

The following procedure details the steps that the Orderly Room clerk must take after a claim has been submitted for review, and prior to sending it to the Plan Administrator. Refer to Annex E - Clerk's Aid Sheet.

• Step 1 - Member or member's dependant has visited the dentist and the member submits the claim.
• Step 2 - If the member is an annuitant on a mandatory break, claim for dental services incurred during the break are ineligible.
• Step 3 - Ensure that the dentist has completed Part 1 of the claim form.
• Step 4 - Determine whether the claim is for a pre-determination of benefits. If the claim is for a pre-determination of benefits, then ensure that the member has not signed Part 1 of the claim form (indicating that services have not been rendered). Go to step 5. If the claim is not for a pre-determination of benefits, then go to step 5.
• Step 5 - Check that each Section in Part 2 of the Claim Form has been completed as follows:
  • Step 6 - Ensure that the member has signed and dated the claim. A claim form that is not signed will not be processed and will be returned to the member.
  • Step 7 - Stamp the claim form with the PRes Health Benefits Stamp only. (Unit stamps shall not be accepted.) Complete with UIC and date claim was stamped.
  • Step 8 - Photocopy claim form and receipts and put on member's Pers File. Mail originals to Great-West Life.

4. Advising your Members - Claims Completion

Undoubtedly, members will have questions or concerns when completing their dental claims. Provided below is some key information that the Orderly Room clerk may communicate to the member. Refer to Annex F Member's Aid Leaflet.

Member's responsibility

Members are responsible for:

• completing the claim accurately (i.e. correct certificate number);
• certifying that the information provided on the claim is correct;
• completing the claim form fully (e.g. signing the form); and
• submitting the claim form to their Orderly Room;

Pre-determination of benefits

Encourage members to get a pre-determination of benefits done, where the member expects the cost to exceed $300.00, before incurring actual expenses. It is in the best interest of the member to determine what will be paid before treatment begins.

When is member registered with administrator?

A member, who is assigned a certificate number and submits the first claim, is not registered as a Plan participant until this first claim is processed. Once the claim is processed, the member is added to the Plan Administrator's system.

Member's certificate number

Once a claim has been processed, the member is issued a card containing a certificate number. It is the member's responsibility to use the correct certificate number whenever they complete a dental claim. Upon receiving the card, the member should be advised to check the identification number and Plan Policy number. See Annex C for the example of an identity card.

Electronic Claims

Many dentists are set up to submit electronic claims to the Administrator. The RDCP has been devised to only accept claims that have been submitted to the Unit Orderly Room and stamped after the clerk has substantiated the claim. Therefore, members employed on Reserve service cannot have their dental claims submitted electronically from their dentist to the Plan Administrator.

Receipts

The member must attach the bills/receipts, giving full details for services rendered, to the claim.

Time frame-submitting claims

The Plan Administrator must receive claims within fifteen (15) months of the date on which the service is rendered.

Claims received after the fifteen-month period shall not be paid unless it was impossible to submit the claim within that time. However, except in the case of legal incapacity, no claim will be paid if it is submitted more than twenty-four (24) months after the service was rendered. For orthodontic treatment. A claim must be received within 15 months of each monthly visit throughout the treatment period.

Limitations, eligible services

Eligible services are contained in the Plan rules.

The CF Dental Care Plan booklet advises all participants with the provisions for exact limitations and eligible services.

Should the member have any concerns regarding the eligible services, the member shall contact the Plan Administrator. The Orderly Room shall not counsel the member on services covered.

Re-direction of payment

A member may have a claim payment re-directed to an eligible spouse. The member shall complete the Authorization to Re-Direct Payment Form at Annex B and submit it with the claim. A member may have payment re-directed to the dentist by completing the appropriate section on the Claim Form at Annex A.

Mailing address changes

Remind the member to inform the Plan Administrator of any changes to their mailing address. Otherwise, the member may not receive payment on the claim.

5. Advising your Members - Claims Payment

The following provides key information regarding what the member may expect after the claim form is submitted to the Plan Administrator (Great-West Life).

Explanation of benefits

When a claim has been approved, Great-West Life will forward an Explanation of Benefits to the member with payment. If the member has requested that payment be issued to the dentist, Great-West Life will send a statement of benefits to the dentist with payment and a copy will be forwarded to the member.

Redirection of payment

• Payment(s) will be issued to the member, unless the member signed and submitted an Authorization to Redirect Payment Form at Annex B to have payment issued to an eligible spouse; *
• The member requested, on the Claim Form, that payment be issued to the dentist.

*Annex B must be attached to each and every claim the member wishes to re-direct payment.

Amount of payment

Payments are normally made in one lump sum; however, for orthodontic services, the Plan Administrator will reimburse the member on a monthly basis, provided receipts are forwarded to the Plan Administrator. The calculations for these payments will be based on the information submitted by the orthodontist on the treatment plan.

Claims disputes

Generally speaking, a disagreement about claims should be handled through the Plan Administrator (Great-West Life). Occasionally, a dispute may occur about the validity of a declined claim. When all other remedies have been exhausted, the matter is to be referred to the Board for consideration.

Section 4: Plan Provisions

1. Overview

Section 4 is a reference section designed to provide information, such as the coordination of benefits, tax implications, and dependant information changes, that is not dealt with elsewhere in this instruction manual.

2. Other Insurance and the Co-ordination of Benefits

The following table details how benefits may or may not be co-ordinated under the Reserve Dental Care Plan.

Member / employee of another insurance plan

Members may not co-ordinate benefits for themselves. A member cannot hold coverage under two plans. Refer to Section 2.

Examples

The following table illustrates whether benefits may or may not be co-ordinated under the RDCP.

Order of claims submission

Payment of benefits will be determined as follows:

• when a member and spouse are co-ordinating benefits in respect of a dependant child, then the claim shall be submitted first to the plan of the parent with the earlier birth date (month/day) in the calendar year.

Statement of benefits

If the member is co-ordinating benefits in respect of a dependant child, as stated above, the member shall be reminded to include a statement of benefits from the other insurance plan (i.e. the first plan) with the dental claim form from the first plan when submitting to the second plan.

Member covered under a parent's plan

A member who is covered as a dependant child under a parent's plan, where the parent's plan is a component of the Public Service Dental Care Plan, may be covered under the Reserve Dental Care Plan only if coverage under their parent's plan is ceased.

A member cannot co-ordinate benefits for him/herself under a parent's plan, if their parent's plan is a component of the Public Service Dental Care Plan.

Province or Territory insures dental services

If a member resides in a province or territory that insures dental services, the member should submit the claim to the provincial/territorial authorities to be processed first. The member may then submit a claim form to the RDCP for remaining eligible expenses.

3. General Plan Provisions

Outlined below are additional Plan provisions, such as tax implications, fee schedule information, dependant information changes, and extended benefits, that the Orderly Room clerk may need to refer to when advising members.

Tax implications

If the member resides in Quebec, contributions from the Federal Government paid towards the Dental Care Plan is considered a taxable benefit for members who reside in Quebec. Therefore, Quebec income tax must be paid on it.

Fee Schedules

Dental expenses incurred on or after 1 January, 2000, will be reimbursed based on the provincial or territorial fee schedule, and Specialist fee schedule where available, in effect the previous year.

Dependant information changes

The member shall inform the Plan Administrator of any changes to dependant information.

Extended benefits: extensive dental treatment or orthodontic services

Refer to Section 2.

4. Contact Information

• Orderly Room clerks/members who have questions regarding clarification on the Dental Care Plan should contact the Plan Administrator directly.
• Members inquiring about the administration of the Reserve Dental Care Plan, should be directed to the Unit Orderly Room clerk.
• If further clarification about the administration of Reserve Dental Care Plan or this instruction manual is required, the Orderly Room clerk shall contact the OPI.

OPI & The Board

Director of Pensions and Social Programs

National Defence Headquarters
MGen George R. Pearkes Building
101 Colonel By Drive
Ottawa, ON K1A 0K2
Attn: CF Dental Care Plan Board
Telephone: 613-996-9581

Plan Administrator Great-West Life Assurance Company

(Members posted outside Canada)

Foreign Benefit Payments Office
P.O. Box 6000
Winnipeg, MB R3C 3A5
Telephone: 204-942-3589
Toll-free: Bilingual 1-800-957-9777

Great-West Life Assurance Company

(Other Canadian Residents - including the National Capital Region)

Health and Dental Claims Centre
P.O. Box 6025
Station Main
Winnipeg, MB R3C 3C7
Telephone: 204-942-3589
Toll-free: Bilingual 1-800-957-9777

Great-West Life Assurance Company

(Quebec residents - other than National Capital Region)

Montreal Benefit Payment Office
Place Bonaventure
800 de la Gauchetiere West
Suite 5800
Montreal, QC H5A 1B9
Telephone: 514-878-1288
Toll-free: Bilingual 1-800-663-2817

5. Reserve Dental Care Plan Rules and Regulations

Current Rules

Currently, the RDCP rules and regulations are under review and will be included in the manual at a later date.

Section 5: Annexes

Overview

This Section contains all the annexes that have been referenced in the manual.

Annex A - Claim Form

Please note that the following form is available on CMP/DGCB's intranet website. If you do not have access to the intranet website, send an email to: Healthanddental-Santeetdentaire@forces.gc.ca and we will provide you with the required form.

• Claim form for CF Reserve (Class A and B Service) Dental Care Plan

Annex B - Authorization to Redirect Payment

Please note that the following form is available on CMP/DGCB's intranet website. If you do not have access to the intranet website, send an email to: Healthanddental-Santeetdentaire@forces.gc.ca and we will provide you with the required form.

• Authorization to Redirect Payment

Annex C - The Clerk's Aid Sheet - Determining Eligibility

These are the necessary steps to take in determing a member's eligibility for the Dental Plan.

Annex D - The Clerk's Aid Sheet - Stamping a Claim

The following will assist Unit Orderly Rooms in processing and stamping a member's dental claim.

Annex E - The Member's Aid Leaflet - Completing a Claim

1. Claim Form

GWL has produced claim forms specifically designed for the RDCP. These forms are available through regular supply channels. GWL will accept Standard Dental Claim Forms, which can be obtained from your Dentist's Office or claim forms produced by the Dentist Office. It is highly recommended that members use the RDCP claim form as it prompts the member to answer questions specific to the RDCP rules and provisions.

2. Patient Information

Ensure patient information is correctly entered. If your Dentist Office keeps a record of your dental information, advise the office of any changes.

3. Dentist Information

To provide GWL with the source of the dental services. This information is critical. (see 4 below)

4. Assigning payment directly to the dentist

The dentist may allow you to direct GWL to remit the payable benefit directly to the dentist. If so, signing here you are authorizing GWL to send the payment directly to the dentist and you will pay the dentist the outstanding balance.

5. Additional Information

If additional information or special consideration is required the dentist will use this space. If you wish to submit a claim for a "Pre-determination of benefits" the dentist will indicate it within this box. (see 6. for further information on Pre-determinations). If a claim is lost and you are re-submitting then the "Duplicate Form" box will be checked off.

6. Acknowledgement of Responsibility

By signing this block you are acknowledging that fees listed may or may not be covered by the RDCP. You are financially responsible to the dentist for these fees and that the fees are accurate for the services rendered. Your signature also authorizes the release of the information contained on the claim form to the insuring company/plan administrator. For a "Pre-determination of benefits" you will not sign this block as the pre-determination is an estimate for proposed services and fees that have not been incurred.

7. Office Verification/Dentist's Signature

Verification from the dentist office that all information given is accurate. This box must be completed by the dentist's office stamp/signature.

8. Statement of Services

Full particulars of service and applicable charges.

9. Member's Name and Initials

Ensure that you enter your name as the plan holder. GWL will cross-reference your name with the certificate number. Your claim will be returned to you by GWL if there is a discrepancy.

10. Plan Number

Ensure that the plan number is 55999 for the RDCP.

11. Member's Certificate No.

Ensure that you enter your initially assigned Certificate Number here. Additional Certificate Numbers, SN, SIN and ID numbers from other plans will not be accepted, and your claim will be returned to you.

12. Member's Home Address

The cheque from the claim shall be mailed to this address. Ensure that this address is correct. If you cannot be reached at the indicated address, GWL will retain your cheque until you notify them of the proper address.

13. Relationship of Patient

If you are on Class A or short-term Class B you may only claim "self". If you are on long-term Class B you may only claim an eligible dependant, "spouse", "child" or "common-law partner".

14. Dependant child over 21

Under this plan you may cover a dependant child up to the child's 21^st birthday. If the child is a student enrolled full-time at an educational institution, you may cover him/her until their 25^th birthday.

15. Common-law partner

Means a person who has been cohabiting with a member in a conjugal relationship for a period of at least one year or for a period less than one year if the member and the person have jointly assumed the support of a child.

16. Benefits under another plan

If you indicate yes and you are the member/employee of the other plan you are not eligible and may not participate in the RDCP.

17. Name of person covered

Indicate name of the member/employee of the other plan. If your spouse or common-law partner is the other policy holder and they are the patient, ensure that the dental expenses are first claimed through their plan. When submitting to cover the difference, attach a copy of the claim form and the "Statement of Benefits" from the other insurance company when you forward your claim to GWL.

18. Policy & ID No.

Ensure the other plan's policy number and the member's ID number listed in the previous block are entered.

19. Name of dental plan/other insurance Co.

Indicate the name of the other plan and which insurance company administers the plan.

20. Coordinating benefits for a child

If your spouse or common-law partner is a member/employee of another plan and the claim is for your child, it is important to enter your date of birth and your spouse/partner's. When coordinating benefits between the two plans, the claim will be first paid under the plan of the individual who was born first in the calendar year and the difference under the other plan.

21. Signature and date

Once you have completed the entire claim form, and not just key areas highlighted here, you must sign and date the claim. There is no provision in the RDCP to allow spouses or common-law partners to sign the claim on your behalf. Claims not signed and dated by the member will be returned to you by GWL.

Note: Please ensure your Orderly Room stamps your claim with the PRes Health Benefits Approval stamp or your claim wil be denied

Annex F - Released Notice to Annuitants on Mandatory Break

Options for Annuitants on 35 Day Consecutive Break for the CF Dental Care Plans

This advisory has been prepared in order to inform CF annuitants serving in the Reserve Force of their options with regard to their dental and health insurance when required to take a 35 day break.

Dental

Members on mandatory break(s) in service are not eligible to participate in the CF Dental Care Plans. Coverage ceases on the last day of service before the break and re commences on the first day of a member's return. During the break(s), members will be responsible for their own dental expenses. Exceptions are possible for orthodontics and certain treatments begun while the member was serving e.g. root canals, but these are rare. See the CF Dental Care Plan Booklet for details.

There are three possible scenarios for dental care coverage for CF Annuitants during their breaks in service:

Scenario #1: The annuitant accepts the fact that they have no dental coverage under the CF or PDSP during their 35 day break and pays for any dental expenses occurring during the break.

Scenario #2: The annuitant has dental coverage as a dependant under their spouse's plan and dental expenses will be re-imbursed through that plan only.

Scenario #3: The annuitant can become covered as a pensioner under the Pensioner's Dental Services Plan (PDSP). This provides you and/or your dependant(s) with constant coverage that remains unaffected by the 35 day break.

Coverage under the Pensioners' Dental Services Plan (PDSP) is only available to an eligible pensioner who initially deferred PDSP coverage and who elects to activate coverage under the PDSP during their break.

What is the Pensioners Dental Services Plan (PDSP)

The PDSP is a voluntary contributory dental care plan for public service pensioners. It was introduced on January I, 2001. An eligible pensioner may defer making an application for membership if the eligible pensioner has coverage under another dental plan or has Veteran's Coverage. An eligible pensioner who wishes to defer application for membership must, within 60 days, so notify the Administrator in writing in the prescribed form and provide proof of that coverage to the satisfaction of the Administrator.

What to do to activate PDSP coverage

Members must apply to activate coverage under the PDSP within 60 days of the cessation of coverage under the CF Dental Plans. This will necessitate the submission of an application form and payment ofPDSP contributions from your pension payments for the period of each and every break. Applications to join the PDSP will take 2 -3 months to process for each break. Members will be deducted the full monthly premium in order to be covered for a partial month.

Full information and enrolment forms for the PDSP can be obtained by calling

Sun Life Assurance Company at 1-888-757-7427 (toll free in North America) or 247-5100 in the National Capital Region.

What to do on return after the break

When resuming active Class C service members must contact their Orderly Room and request a new Dental Start in Peoplesoft in order to register as a participant in the Dependants Dental Care Plan.

Those resuming active Class B service must terminate their coverage under the PDSP in order to participate in the Primary Reserve Dental Care Plan.

Members who take multiple breaks throughout the year in lieu of one 35 day break will be required to complete this administrative process for each and every break.

Do not assume that this ensures smooth coverage. Movement in and out of the PDSP for short periods, (when not covered by the CF Dental Plans), will be administratively cumbersome and delays in stopping and starting contributions and coverage can be expected. There may be restrictions on dental services for members who enter and leave the plan. This could seriously affect any reimbursement on lengthy dental procedures.

Roles and Responsibilities

DPSP is the OPI for the CF Dental Care Plans. The CF Dental Care Plans comprise of the Dependants Dental Care Plan and the Primary Reserve Dental Care Plan. These plans are administered by Great-west Life Assurance Company of Canada.

The Treasury Board of Canada Secretariat is the OPI for the Pensioners' Dental Services Plan (PDSP), which is administered by Sun Life Assurance Company of Canada. It has separate rules and provisions from the CF Dental Plans.