Have you ever looked at the claim form completed by the dentist and noticed that numeric codes almost outnumber words? Dental codes are a language with which insurance companies and dentists communicate. In an age where electronic dental interchange (EDI) is the norm for processing claims, the units and codes are how the insurance companies manage the dental service claimed and reimbursement for those services.  

One of the most  frequent procedures and claims is scaling (measured in “units”); basically the process of removing dental tartar from the surfaces of the tooth. An invoice from a dentist may indicate that a patient has had one (or two, or three) units of dental scaling. The term “unit” is slightly misleading as it seems to indicate a specific quantity of plaque removal when in fact it does not. One unit of scaling equals 15 minutes.

If you have had  dental benefits for years, you may have noticed the coverage for scaling units has changed over time.

When dental plans were first designed, periodontal scaling was a time consuming surgical procedure performed by a dentist (general practitioner) or periodontist (specialist).  Scaling represented such a small portion of dental claims it never got much attention … until claims began increasing at a very significant rate of 30-60% per annum. The impact of scaling on claims cost was not the only reason for the change in scaling unit allotment.  Dental hygiene in developed countries has improved considerably over the years and technology has improved the efficiency and efficacy with which scaling is performed.

A combination of cost control, the historical improved dental hygiene, and technological advancement in scaling procedures  have lead plan sponsors and insurers to reduce the units of scaling gradually over time from 16 units of 15 minutes (4 hours) per year, then 12 units (3 hours), then 8 units (2 hours) and more recently 6 units (1.5 hours).

For the consumer, it is not only important that the dentist be aware of the scaling unit coverage, but that as the consumer of benefits, you are aware of what procedures were completed and billed correctly.

• Expenses…minimize these
• Claims…control them
• Communication… enhance it
• Administration…ensure competency and consistency

Administration is a key part of best practices plan management. Without excellent administration an employer can be at substantial risk of liability. Liability can arise from a number of areas, a few which are as follows:

• Enrolment – ensuring all eligible employees are enrolled and conversely ensuring those not eligible are not on the plan

• Non-evidence maximums (NEMs) – we see this time and time again…employees that are vastly underinsured because their salaries exceed the NEMs for life insurance and long-term disability. Insurance companies will provide a maximum amount of coverage for these two benefits without employees having to provide medical information. For coverage above this limit often the first and only step is for the employee to complete a health form which will allows them, after proving satisfactory health, additional coverage.

• Proper communication of the timing and benefit options available for terminating employees – conversion of life insurance and other benefits is provided within a specific time period.

• What to provide in the way of continuation of benefits coverage for employees that become disabled.

Proper administration can save both time and money. Time in not having to deal with delicate or legal issues that should have been addressed beforehand and money in not have to pay for legal representation if suit is brought against the employer. These two items are the additional costs of poor benefits plan management – ones that do not come directly from the actual plan itself.

It is suggested that annually a checklist be completed checking off all the important areas of administration with the focus to protect against all potential areas of liability and to ensure smooth day to day plan administration.

Ken Hicks
Managing Partner
Titan Recruitment Solutions

By Brent Delveaux and Queenie Yeung

“Age is an issue of mind over matter. If you don’t mind, it doesn’t matter” – Mark Twain

“But it matters with benefit plans!” – Brent Delveaux

We are an aging population, a reality that is not going to change any time soon.  2011 was the year the first of the “baby boomer” generation turned 65.  We are also living longer than ever before with life expectancy in Canada now exceeding 80 years in 2010[i].

When it comes to benefit plans, an aging population creates serious issues for benefit plan sponsors. Many benefits, such as life insurance and long term disability, incorporate an age limitation and benefits just cease when that age is reached by an employee. If you have older employees who want to keep working and stay on the benefit plan, you could ask your insurer to increase or eliminate the termination age for most benefits; but is this the right decision for your organization?

In Canada, you can no longer force an employee to retire because of age, but benefit plans are still permitted to terminate due to age.  When designing benefit plans, we encourage employers to think about what is best for their company given the conventions and standard practices of the industry or market they are in. For example, if the company operates in an industry where it is hard to find employees, they may need to entice employees to continue working past regular retirement age and if they do remain active, employers may have to continue benefits.

In reviewing your decision, you must consider that healthcare costs rise significantly with age so you may not want to leave the termination age open ended, however, some employees will want to continue to work and not retire because they have large recurring medical claims they cannot afford.

This is a difficult subject and it will affect all employers at some point in time. No one wants an employee to experience financial hardship but can your business afford to continue providing coverage?

Sadly, it often takes a mental health crisis or traumatic event in the workplace to create organizational awareness of mental health issues. At that moment, energy is focussed on locating and delivering resources to the individual or individuals impacted during a crisis. Planning for mental health wellness or developing a strategy for workplace mental health is rarely discussed or considered.

While it is necessary to have procedures in place, including identifying various resources that may be relied upon during a mental health crisis, it is equally important to have a strategy to promote mental health and have an environment that can play a positive role in managing mental illness in the workplace.

A lack of awareness tends to have organizations focus on the day to day management of minor, easily identifiable mental health issues. Even though focus might be on minor mental health issues, having an understanding and protocols established for mental health emergencies is important.

There is a lot of evidence that as a society, we are making progress in elevating the mental health conversation and the media is playing a positive role in removing the stigma attached to mental illness. Consider Bell’s Let’s Talk initiative this past February, which attracted almost 100 million tweets, and you can see clearly that Canadians are becoming aware and share in the concern.  Positive changes are beginning to emerge.

It will take considerable effort and intentional advocacy to create or enhance mental health in the workplace. Establishing priorities within your organization and beginning to strategize in the following areas might be a good place to start:

• Increase awareness about how to promote mental health and prevent mental illness wherever possible, thereby reducing the stigma

• Create a workplace that fosters positive mental health through having a sense of belonging, good interpersonal relationships and good physical health

• Have a strategy to intervene early

The problem is not going away and perception might be that it is a growing issue. It is more likely though that the issue has moved into mainstream discussions. This is a good thing and hopefully meaningful outcomes in the workplace will result.

Many employers are looking for creative ways to enhance the compensation package of their key employees.  A grouped individual critical illness arrangement is one of the many possible solutions.  This arrangement involves a number of individual policies which are grouped together to form a “Group Sickness or Accident Plan” for income tax purposes.

A Group Sickness or Accident Plan is not defined in the Income Tax Act.  However, the CRA has indicated in correspondence that a group plan is a plan under which two or more employees are insured, either under a single master contract between the insurer and an employer or under individual contracts pursuant to a common plan.

The following criteria must be met in order to qualify as a Group Sickness or Accident Plan:

-          two or more employees must participate in to form a “group”

-          the plan must be documented

-          the lump sum CI benefit must be paid directly to the insured person under the plan

-          the CI policies must qualify as accident and sickness insurance for income tax purposes

There are many advantages to implementing a “Grouped Critical Illness” program for both the employer and employees.  For the employer, the premiums can be a tax-deductible expense, help attract key employees and is an expression of care to employees at a time of critical need.  For employees, they receive a portable insurance policy upon termination or retirement from the company and premiums are paid by the employer while employed under the grouped arrangement.

Absorbing the costs of health and dental benefits for employees on Long-term Disability (LTD) can be expensive.  Many plan employers are under the assumption that they must continue providing health and dental coverage because of a legal obligation, or because their insurance carrier will decide when these benefits will end. Neither assumption is accurate.

The continuation of benefit coverage is corporate policy and part of the employer’s responsibility under a ‘duty to accommodate’ employees on disability. How long to continue coverage should be addressed in on hiring through a carefully worded employment policy.  Ideally, this needs to be communication to all employees and if possible, written into an employment agreement or policy handbook.

Establishing a policy in advance is an important way to protect employees and yourself from unwelcome surprises and legal liability.

Every employee in BC is covered under WCB/WorkSafe BC. If an employee is injured on the job they can apply to WCB/WorkSafe BC for disability benefits at the same time they apply for either  Short Term Disability/Weekly Indemnity (if applicable), Employment Insurance (if no STD/WI is available) or Long Term Disability benefits under their group insurance policy.

Coordinating your Group LTD and Workers Compensation Board (WCB/WorkSafe BC) claims can save time & money.  As a plan administrator you should notify your Group Insurer of WCB claims to take advantage of the Waiver of Premium privilege under the group policy.

Most contracts allow for the waiver of monthly premiums for group life insurance, accidental death & dismemberment and disability benefits while an insured is receiving disability income benefits including WCB.  In order to apply your insurer must be advised within a year of the disability that the member is on claim.  The waiting period for waiver of premium can vary depending on the contract and the insurer in question, but is generally either four or six months after the date last worked.

It is most important to keep accurate records through the WCB application process as you will need to provide the necessary proof and paperwork to your insurer to apply for waiver of premium. Doing so in a timely basis can indeed save you time and money!

One of the most significant events for all stakeholders in a Long-Term Disability (LTD) claim is the transition from “Own Occupation” definition of disability to “Any Occupation.”  This is commonly called ‘change of definition’ and typically occurs after 24 months of LTD benefits.  The criteria to qualify for ongoing disability benefits changes from an individual being disabled from the duties of their own occupation to being disabled from performing the duties of any occupation for which they are reasonably suited by their education, training, and experience.

Under this stricter definition of disability, the insurance provider conducts a very thorough and detailed assessment which typically requires several months of review by Case Managers, Disability Specialists, medical consultants, and other experts.  The review includes all available medical information, specialist reports and consultations, a detailed telephone interview with the plan member in most cases, and an evaluation of an employee’s education training and experience relative to their restrictions and limitations.  There are other non-medical factors taken into consideration as well, such as a concurrent application to CPP Disability benefits, etc.

Considerations before approval of benefits in the “any occupation” definition of disability include:

• Does the employee have the ability to perform other work that they are suited for by way of education, training, and experience and that is commensurate to their current earnings?
• Is it possible to re-train the employee for a new role with their current employer?
• Are there workplace accommodations that can address the limitations that the employee may have?
• Is re-training for a role at a different company feasible?
• Is the disability total and permanent?

This process can be a confusing and stressful event for the disabled employee, and there are several ways a Plan Sponsor can support them and make the transition easier.

First and foremost, it is highly recommended that companies have a policy in place on how they deal with disabled employees, particularly at the change of definition.  How long does the disabled individual remain an employee?  Do they stay on the benefits program indefinitely?  Are they considered an employee until retirement?  Does the company policy comply with labour standards and human rights legislation?  Is there a formal process in place to assist them in returning to work or making accommodations for their restrictions / limitations?  These are just a few examples of the many important and complex questions that Plan Sponsors may wish to address through company policy so they can communicate clearly to establish expectations to all employees prior to an LTD claim occurring.

Secondly, Plan Sponsors can encourage the disabled employee to ask their doctor to provide all relevant information to the insurance company.  The disabled employee having this conversation with their doctor up front can potentially avoid several months of back and forth communication between the employee’s doctor and the insurance company.

Finally, Plan Sponsors can contact their Benefits Consultant who should be able to liaise with the insurance company and provide Plan Sponsors with more specific advice related to their particular situation.

The short answer is..yes! And not just to make life difficult for clients and employees.

A number of basic underlying principles make group plans a convenient way in which to insure employees generally with very little health information being asked. To make this happen, a number of assumptions are made and procedures must be followed to avoid employees from selecting against the insurer (anti-selection).

Some of these common principles in group contracts include employees being actively at work and employees and their dependents enrolling in the group benefits program within 31 days of their becoming eligible. This not only applies when an employee joins the plan, but if there is a lifestyle change such a marriage, reaching common law status, or adding dependent children to the plan. The reason for this, in simplest terms, is that if employees were given the option to join a plan whenever it suited them, it goes to reason they may only join the plan when the need arose or they had claims. This selection against the carrier is a disadvantage not only to the insurance company but to all in the group plan. The end result is the potential to leave few non-claimers paying premiums, and a plan filled with only those using the plan. More claims – fewer premiums, leading to insurance costs and less plan sustainability for all.

So what happens if an employee, and employer, does not enroll eligible employees and dependents within the required timeframe? A lot more headaches! The enrollment or change can still occur but the insurance carrier will treat the transaction as late or classify the employee as a “late applicant”. With this, a pandoras box gets opened that will at the very least cause extra work and may even create a liability situation for the employer. The carrier will ask for details around the change and will most likely include questions about the applicant’s health. It may even require contact with physicians to obtain medical files.

A decision on whether the insurer is willing to provide coverage will be made by the insurance carrier, and for a late applicant, it is the insurance carrier’s prerogative to allow or decline the coverage. If the insurance company does agrees to cover the employee, or make the change, the headache may not end there. Most group policies have limitations imposed that will see dental amounts limited in the first year, usually to $250.  Unlike healthcare, where the health history is being investigated and health questionnaires have been requested, this dental restriction exists because there is less likelihood of the insurance carrier having a clear picture of person’s dental health, or uncertainty in risk for claims in the near future.

After the first year, however, the late applicant’s annual maximum dental benefits are restored to the full amount. For good measure, while the restriction is being applied, full dental premiums are required.  So to avoid the pitfalls of being a late applicant or have the change considered late, keep in mind that timing does matter. As an employer, being aware will help mitigate potential issues even the possibility of declined coverage.