Treasury Board of Canada Secretariat
Public Service Health Care Plan for Pensioners


GENERAL

The Public Service Health Care Plan is a private health care plan sponsored by the Government of Canada for the benefit of employees and pensioners of the federal Public Service, Canadian Forces, Royal Canadian Mounted Police (RCMP), and certain designated agencies and corporations.

The purpose of the Health Care Plan is to provide participants and their eligible dependants with coverage, up to reasonable limits, for unexpected expenses for specified medically required services and products.

Effective August 1, 1991, certain fundamental changes were made to the funding of the Group Surgical-Medical Insurance Plan (GSMIP), and as a result, the plan became known as the Public Service Health Care Plan. The plan is now operated on a self-insured basis, which essentially means that the plan assumes full liability for the payment of all costs related to the operation of the plan, including the payment of claims. The monthly contributions (member and government shares) are managed by the plan’s Board of Management and are used to fund all of the plan’s operations.

A contract has been entered into with an insurance company to adjudicate and pay claims, in accordance with the Plan Document. The insurance company is hereafter referred to as the Administrator.

The Board of Management is composed of management and union representatives of the National Joint Council, and is responsible for overseeing the finances of the plan and for contracting with the Administrator and other providers of services. The Board monitors all aspects of the plan’s financial performance and reports, as required, to the National Joint Council. The Board periodically reviews the plan benefits and recommends appropriate changes, and also reviews cases involving difficulties and disputes over membership and individual claims arising from the administration of the plan (see Appendix C – Claims).

In using this booklet you may wish to note that:

To simplify descriptions throughout the booklet, the term "pensioners" is used to describe all eligible pensioners, unless otherwise specified. Similarly, the term "pension office" is used to denote all offices which administer benefits for pensioners.

Appendix D sets out the addresses of the largest offices for pensioner enquiries.


Section I – Provisions Applicable to All Pensioners

Eligibility to Join the Plan

Membership in the Health Care Plan is generally available to persons in receipt of pensions under the Superannuation Acts for the federal Public Service, Canadian Forces, and RCMP, as well as certain other federal pension legislation, but there are a few exceptions and special conditions in certain cases. Membership in the Health Care Plan is optional for pensioners, and a pensioner may apply to join the plan, or amend his or her coverage, at any time while in receipt of the pension. However, if you do not apply to join the plan when you first become eligible, or later wish to increase your coverage, your new or amended coverage will only come into effect after a waiting period.

Upon becoming entitled to payment of your pension, your pension office (see Appendix D) will contact you, and will provide details concerning your eligibility to join the plan.

If you are a member of the plan immediately prior to retirement, and become entitled to an annuity or an annual allowance on retirement, you may remain a member of the plan as a pensioner. If you were not a member of the plan immediately prior to retirement, you may apply to join the plan as a pensioner.

If, upon retirement, you are not entitled to an immediate pension, and choose a deferred annuity or an annual allowance which becomes payable at a later date, you may apply to join the plan as a pensioner only when your pension becomes payable. (An employee who retires, and chooses a deferred annuity or annual allowance which is not payable on the date of retirement, cannot continue coverage during the interim.)

If you are a widow(er) of a deceased member of the plan, and become entitled to a widow(er)’s pension under one of the Acts mentioned above, you are eligible to join the plan when your pension becomes payable.

You must apply to either join the plan, or amend your coverage, within 60 days of becoming eligible to do so. Otherwise, if you apply at a later date, coverage will only take effect from the first day of the fourth month following the date your application form is received in your pension office.

Applying to Join the Plan

If you are interested in joining the Health Care Plan or you are already a member and you would like to amend your level of coverage, you must complete a Health Care Plan application form, which is available from your pension office.

Coverage for Dependants

As a pensioner, you may apply to cover your eligible dependants under the Health Care Plan, either at the time you apply to join the plan yourself, or at a later date. However, once you have "family" coverage, you need not apply to cover any additional dependants.

A person cannot be claimed as a dependant by more than one member of the plan. For example, if you and your spouse have “family” coverage under the plan, only one of you may claim the expenses for your children (see Appendix C – Claims).

Eligible Dependants

Eligible dependants consist of the following:

  1. your spouse (including a common-law spouse – your pension office can provide additional details);
  1. your unmarried children (including an adopted child, step-child or foster-child) who are:
If a child becomes “impaired” after reaching age 21, and at that time is not covered under the Health Care Plan as a student, that child is not eligible to be covered under the plan.

Your Monthly Contribution

The entire operations of the plan, including the payment of benefits, are financed by the monthly contributions of plan members and the government, as employer. The contribution which a member of the plan is required to pay depends on the coverage chosen.

As the employer, the government pays 80 per cent of the cost for pensioners for coverage under the Extended Health Care Plan, and the full additional contribution for coverage under Level I of the Hospital Benefit. An additional monthly contribution is payable for Level II or Level III coverage under the Hospital Benefit.

The overall pensioner contribution, plus the government’s contribution, must be sufficient to fully fund the total claims costs and related administrative expenses for pensioners. If the claims costs for pensioners increase, then periodic increases to the pensioner contributions are necessary. Because the Health Care Plan is a group plan, the claims costs for all pensioners, as a group, are taken into account in establishing the contribution rates. The rates are therefore the same for all pensioners, and no differentiation is made for other factors such as age or province of residence.

The contributions which you are required to pay are normally collected by deduction each month from your pension, and are payable one month in advance to provide you with coverage for the following month.

Whenever changes are made to the contributions, you will be informed by your pension office and this information should be retained by each pensioner for reference. You should periodically ensure that the correct monthly contributions are being deducted from your pension.

Pensioners who are paying monthly Health Care Plan contributions from their pension, and who become employed in the Public Service, may choose to be covered under the Health Care Plan as employees if they are eligible. However, it is your responsibility in this case to advise your pension office to discontinue deductions of Health Care Plan contributions from your pension, and to apply for coverage under the Health Care Plan as a Public Service employee. Your Personal Identification Number will remain the same.

Personal Identification Number

When you first apply to join the plan and your application has been approved, you will be issued a benefit card which you should retain in your possession for easy reference. This benefit card will show the Personal Identification Number which has been assigned to you, and the level of coverage you have chosen.

You must be sure to record this Personal Identification Number on any claims which you submit in respect of yourself and any of your covered dependants, and on any correspondence with the Administrator (see Appendix C – Claims). A new benefit card will be issued to you whenever you amend your Health Care Plan coverage, if the information on the card changes. Your Personal Identification Number will remain the same.

Termination of Coverage

You may voluntarily terminate your membership in the Health Care Plan at any time by notifying your pension office in writing. Coverage will cease no later than two months following the date your notification is received in the pension office. Any deductions from your pension will cease the first of the month prior to the date of cessation of coverage.

Example: You write to your pension office in January to cancel your coverage under the Health Care Plan. Your pension office receives your notification in February. Your coverage will cease no later than May 1. Any deductions from your pension will cease no later than April 1.

Section II – Available Coverage

In broad terms, the Health Care Plan is designed to provide two separate types of coverage. These types are:

Supplementary Coverage

This coverage is intended for eligible pensioners who are Canadian residents and are covered under a provincial health plan. In general, the Health Care Plan supplements the coverage provided under the provincial plan in your province of residence. This coverage consists of the Extended Health Care Benefit and the Hospital Benefit (both described in detail later in this booklet).

Comprehensive Coverage

This coverage is intended for eligible pensioners who are residing outside Canada and who are not covered under a provincial health plan. This coverage consists of the Basic Health Care Benefit, the Extended Health Care Benefit, and the Hospital Benefit.

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The three benefits mentioned above (Extended Health Care Benefit, Hospital Benefit and Basic Health Care Benefit) have been designed for different purposes. The exact combination of benefits which is available to you, and the conditions of membership, depend upon which of the following categories you are in:

  1. Pensioners resident in Canada who are covered under a provincial health plan;
  1. Pensioners resident outside Canada who are not covered under a provincial health plan.

Once you have established which category you are in, you will find all of the general information you will need under that category heading in the following pages.

1. Pensioners resident in Canada who are covered under a provincial Health Plan

2. Pensioners resident outside Canada who are not covered under a Provincial Health Plan

Coverage for standard ward hospital charges (and certain other in-hospital expenses) is not available to pensioners residing outside Canada. If you require coverage for hospital expenses in addition to the coverage provided under the Hospital Benefit, you must make personal arrangements to obtain that coverage through some other source.

Section III – Description of Benefits

Extended Health Care Benefit

The purpose of this benefit is to provide coverage for specified services and products which are not usually covered under provincial health plans, or alternatively, in the case of members resident outside Canada, which are not covered under the Basic Health Care Benefit of the Health Care Plan.

Subject to the following conditions, expenses which you incur for the various services and products are eligible for reimbursement under the Extended Health Care Benefit. Reasonable and customary charges for certain services and products other than those listed below, may also be approved by the Health Care Plan Board of Management as eligible expenses.

From time to time, changes are made to the coverage provided under the Health Care Plan. You will be informed of such changes by your pension office and you should keep a record of these changes for future reference.

Conditions

1. Reasonable and Customary Charges

2. Limits on Eligible Expenses

Deductible Amount

For each calendar year, there is a minimum deductible amount; only the eligible expenses incurred by you during the year which exceed that deductible amount are eligible for reimbursement under the Extended Health Care Benefit. The annual deductible amount is $25 per person. If you have "family" coverage, but only one member of your family "unit" incurs eligible expenses in a calendar year, the annual deductible of $25 will apply to those expenses. Where eligible expenses are incurred in a calendar year in respect of more than one member of a covered family unit, then the combined deductible amount which must be exceeded for all members of that family "unit" will be limited to $40 for that calendar year.

Co-Payment/Reimbursement

Except where otherwise stated, such as under the Travel Benefit, the Extended Health Care Benefit will reimburse you 80 per cent of the reasonable and customary charges which you have incurred for a particular covered service or product above the annual deductible amount. This is subject to any limits which may be in place on the amount of eligible expenses which may be covered for that product or service. The remaining 20 per cent of such eligible expenses must be paid by you, and is referred to as the co-payment.

Eligible Expenses under the Extended Health Care Benefit

The Extended Health Care Benefit is comprised of the following benefits:

Drug Benefit

Definitions under the Drug Benefit

Chronic disease means a condition that exists beyond the usual course of an acute disease or beyond a reasonable time for tissue damage to heal. Any such condition that lasts longer than six months may be considered chronic.

Dentist

means a person licensed to practice dentistry by the provincial licensing authority, or in the absence of such authority, a person with comparable qualifications as determined by the Administrator.

Registered pharmacist

means a person who is licensed to practice pharmacy and whose name is listed on the pharmacists’ registry of the licensing body for the jurisdiction in which such person is practising.

Physician

means a doctor of medicine (M.D.) legally licensed to practice medicine.

Members of the plan who are eligible to claim prescription drug expenses under a provincial "pharmacare" program should first submit their claim to the provincial authorities (see Appendix C – Claims).

Eligible Expenses Under the Drug Benefit

Eligible expenses are the reasonable and customary charges for the following items of expense, provided they are medically necessary for the treatment of disease or injury, prescribed by a physician or dentist and dispensed by a registered pharmacist or physician:

  1. drugs, including oral contraceptives, which legally require a prescription and are identified in the Monographs section of the current Compendium of Pharmaceutical and Specialties as a narcotic, controlled drug, or requiring a prescription;
  1. life-sustaining drugs which may not legally require a prescription and are identified in the Therapeutic Guide section of the current Compendium of Pharmaceutical and Specialties under the following headings:
  1. drugs which are identified in the Monographs section of the current Compendium of Pharmaceutical and Specialties as not legally requiring a prescription but which are only available for purchase at an accredited pharmacy and which, in the Administrator’s opinion, have a known therapeutic value;
  1. replacement therapeutic nutrients prescribed by an accredited medical specialist for the treatment of an injury or disease, excluding allergies or aesthetic ailments, provided that there is no other nutritional alternative to support the life of the member or covered dependant;
  1. injectable drugs, including injectable allergy serums administered by injection;
  1. compounded prescriptions, regardless of their active ingredients;
  1. needles, syringes, and chemical diagnostic aids for the treatment of diabetes;
  1. vitamins and minerals which are prescribed for the treatment of a chronic disease, when in accordance with customary practice of medicine, the use of such products are proven to have therapeutic value and no other alternatives are available to the patient;
  1. drug delivery devices to deliver asthma medication which are integral to the product, as approved by the Administrator; and
  1. aerochambers with masks for the delivery of asthma medication to children under six years of age.

Exclusions under the Drug Benefit

No benefit is payable for:

  1. expenses for drugs which, in the Administrator’s opinion, are experimental;
  1. publicly advertised items or products which, in the Administrator’s opinion, are household remedies;
  1. expenses for contraceptives, other than oral;
  1. expenses for vitamins (except injectables), minerals, and protein supplements other than expenses that would qualify for reimbursement under Eligible Expenses under the Drug Benefit;
  1. expenses for therapeutic nutrients other than those that would qualify for reimbursement under Eligible Expenses under the Drug Benefit (#4);
  1. expenses for diets and dietary supplements, infant foods and sugar or salt substitutes;
  1. expenses for lozenges, mouth washes, non-medicated shampoos, contact lens care products and skin cleansers, protectives, or emollients;
  1. expenses for surgical supplies and diagnostic aids;
  1. expenses for drugs which are used for cosmetic purposes;
  1. expenses for drugs which are used for a condition or conditions not recommended by the manufacturer of the drugs; and
  1. expenses incurred under any of the conditions listed in Appendix B.

Vision Care Benefit

Definitions under the Vision Care Benefit

Ophthalmologist means a person licensed to practice ophthalmology.

Optometrist

means a member of the Canadian Association of Optometrists or of a provincial association associated with it, or in the absence of such association, a person with comparable qualifications as determined by the Administrator.

Eligible Expenses Under the Vision Care Benefit

Eligible expenses are the reasonable and customary charges for the following items of expense:

  1. eye examinations by an optometrist, limited to one examination in a 24-month period; and
  1. eyeglasses and contact lenses that are necessary for the correction of vision and are prescribed by an ophthalmologist or optometrist, and repairs to them, limited to the maximum eligible expense specified in Appendix A.
To simplify the administration of the 24-month limitation on eyeglasses and contact lenses, effective January 1, 1993, all members of the Health Care Plan, and their dependants, will have the same two-year period in which to claim up to the stated maximum for the purchase cost of eyeglasses and contact lenses.

For example, you may claim up to $200 on the purchase cost of eyeglasses and contact lenses for yourself and/or your dependants during the two-year period from January 1, 1993, to December 31, 1994. Once you have claimed expenses up to the maximum for that two-year period, (which is $200 for the two-year period January 1, 1993, to December 31, 1994), you are not eligible to claim further expenses for eyeglasses or contact lenses until the new two-year period commences, i.e., from January 1, 1995, to December 31, 1996, and so on.

Members should note there is no limit on the initial purchase of eyeglasses or contact lenses that are required as the direct result of surgery or an accident, if they are purchased within six months of such surgery or accident. This is identified as a separate eligible expense. This time limit may be extended if the Administrator determines the purchase could not have been made within the time frame specified.

The purchase of artificial eyes, and replacements thereof, also is an eligible expense, but not within:

  1. 60 months of the last purchase in the case of a member or dependant over 21 years of age, or
  1. 12 months of the last purchase in the case of a dependant 21 years of age or less.

Exclusions under the Vision Care Benefit

No benefit is payable for expenses incurred under any of the conditions listed in Appendix B.

Health Practitioners Benefit

Definitions under the Health Practitioners Benefit

Chiropodist/ Podiatrist means a person licensed by the appropriate provincial licensing authority, or in those provinces where there is no licensing authority, members of the Canadian Association of Foot Professionals, or in the absence of such an association, a person with comparable qualifications as determined by the Administrator.

Chiropractor

means a member of the Canadian Chiropractic Association, or of a provincial association affiliated with it, or in the absence of such association, a person with comparable qualifications as determined by the Administrator.

Electrologist

means a person who, as determined by the Administrator, qualifies as a certified electrologist.

Hospital

means a legally licensed hospital which provides facilities for diagnosis, major surgery and the care and treatment of a person suffering from disease or injury on an in-patient basis, with 24-hour services by registered nurses and physicians. This includes legally licensed hospitals providing specialized treatment for mental illness, drug and alcohol addiction, cancer, arthritis and convalescing or chronically ill persons. This does not include nursing homes, homes for the aged, rest homes or other places providing similar care.

Naturopath

means a member of the Canadian Naturopathic Association or any provincial association affiliated with it, or in the absence of such association, a person with comparable qualifications as determined by the Administrator.

Nurse

means a registered nurse, registered nursing assistant, licensed practical nurse, and certified nursing assistant who is listed on the appropriate provincial registry and, in the absence of such registry, a nurse with comparable qualifications as determined by the Administrator.

Osteopath

means a person who holds the Degree of Doctor of Osteopathic Medicine from a college of osteopathic medicine approved by the Canadian Osteopathic Association, or in the absence of such association, a person with comparable qualifications as determined by the Administrator.

Physician

means a doctor of medicine (M.D.) legally licensed to practice medicine.

Physiotherapist

means a member of the Canadian Physiotherapy Association or of a provincial association affiliated with it, or in the absence of such association, a person with comparable qualifications as determined by the Administrator.

Psychologist

means a permanently certified psychologist who is listed on the appropriate provincial registry in the province where the service is rendered, or in the absence of such registry, a person with comparable qualifications as determined by the Administrator.

Registered massage therapist

means a person licensed by the appropriate provincial licensing body, or in the absence of a provincial licensing body, a person whose qualifications the Administrator determines to be comparable with those required by a licensing body.

Speech language pathologist

means a person who holds a Master’s degree in speech language pathology and is a member or is qualified to be a member of the Canadian Speech and Hearing Association or any provincial association affiliated with it, or in the absence of such association, a person with comparable qualifications as determined by the Administrator.

Eligible Expenses Under the Health Practitioners Benefit

To be eligible, the services of these practitioners must be medically necessary for the treatment of disease or injury. Eligible expenses for the services of a practitioner include only those services which are within his or her area of expertise and require the skills and qualifications of such a practitioner.

Eligible expenses are the reasonable and customary charges for:

  1. physician’s services, where such services are not eligible for reimbursement under your provincial health insurance plan, but where such services would be eligible for reimbursement under one or more other provincial health insurance plans;
  1. services of a nurse providing private duty nursing services where such services are rendered in the patient’s private residence, subject to the maximum eligible expense specified in Appendix A. To be eligible, the expenses must be medically necessary for the treatment of disease or injury, and be prescribed by a physician;
  1. the services of the following practitioners, limited to the maximum eligible expense specified in Appendix A for each practitioner:
  1. electrolysis treatments performed by a physician; reimbursement is limited to treatment for the removal of excessive hair from exposed areas of the face and neck, when the patient suffers from severe emotional trauma as a result of this condition. Reimbursement is limited to the maximum eligible expenses specified in Appendix A;
  1. utilization fees for paramedical services which are imposed by the government under the provincial health plan in the person’s province of residence, where law permits a person to be reimbursed for such charges; and
  1. acupuncture treatments performed by a physician.

Exclusions under the Health Practitioners Benefit

No benefit is payable for expenses incurred under any of the conditions listed in Appendix B.

Dental Benefit

Definitions under the Dental Benefit

Dentist means a person licensed to practice dentistry by the provincial licensing authority, or in the absence of such authority, a person with comparable qualifications as determined by the Administrator.

Fee guide

refers to charges established by provincial dental associations for specified services provided by dentists in their provinces.

Eligible Expenses Under the Dental Benefit

The Health Care Plan covers only expenses for specified oral surgical procedures, and for certain dental treatment required as the result of an accident.

Oral Surgical Procedures

Eligible expenses means reasonable and customary charges for the following oral surgical procedures performed by a dentist.

Accidental Injury

The services of a dental surgeon, and the charges for dental prosthesis, are eligible expenses under the Dental Benefit, when required for the treatment of a fractured jaw or for the treatment of accidental injuries to natural teeth if the fracture or injury was caused by an external, violent and accidental injury or blow other than an accident associated with normal acts such as cleaning, chewing and eating, provided the treatment occurred within the 12 months following the accident or, in the case of a child under 17 years of age, before the child attained 18 years of age. This time limit may be extended if, as determined by the Administrator, the treatment could not have been rendered within the time frame specified. A physician’s prescription is not required.

Exclusions under the Dental Benefit

No benefit is payable for expenses incurred under any of the conditions listed in Appendix B.


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