Treasury Board of Canada Secretariat
Public Service Health Care Plan for Pensioners
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 plans Board of Management and are used to fund all of the plans 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 plans 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.
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.
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.
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 consist of the following:
under 21 years of age;
between 21 and 25 years of age and in full-time attendance at school;
21 years of age or over and wholly dependent upon you because of a physical or mental impairment, if such impairment existed prior to the childs reaching age 21, or commenced while the child was covered as a student over age 21. The first time you submit a claim after your child reaches age 21, you may be required to provide medical documentation of your childs impairment.
|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.|
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 governments 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.|
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.|
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.|
In broad terms, the Health Care Plan is designed to provide two separate types of coverage. These types are:
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).
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.
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:
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.
If you are in this category, you are eligible for Supplementary coverage. This coverage consists of the Extended Health Care Benefit, plus the Hospital Benefit. You are automatically covered for Level I of the Hospital Benefit, with the government paying the full contribution for Level I on your behalf. You may choose not to enrol in the plan at all, but if you do join, you may not choose the Hospital Benefit without the Extended Health Care Benefit. Additionally, certain other expenses are eligible where they are incurred outside the participants province of residence. Refer to the Out-of-Province Benefit.
The Basic Health Care Benefit is not available to persons in this category.
Your coverage is strictly voluntary. You must decide the extent of coverage (if any) you wish to apply for (i.e., the level of hospital coverage) in respect of yourself and any eligible dependants.
If you are eligible and wish to be covered under the Health Care Plan, or wish to amend your existing coverage, you must complete a Health Care Plan application form and submit it to your pension office.
If, as a member of the Health Care Plan, you cease to be employed, and are entitled to an immediate annuity or annual allowance, your coverage continues automatically. Deductions will be taken from your pension cheque. Please contact your pension office for contribution rates.
If you are not a member, and you apply within 60 days of being eligible, coverage is effective the first of the month following the month your pension office receives your completed application form. You may obtain an application form from your pension office.
If you acquire a new dependant (i.e., a spouse or child), you should consult your pension office as soon as possible. If an application is required to cover that dependant (i.e., to increase your coverage from "single" to "family"), again the application form must be received within 60 days of the date the dependant became eligible in order for coverage to become effective from that date.
If you do not apply for coverage within 60 days of being eligible, or if you do not apply to upgrade your coverage from "single" to "family" within 60 days of acquiring a new dependant, the revised coverage will only take effect after a three-month waiting period (i.e., from the first day of the fourth month following receipt of your application by your pension office). This waiting period also comes into effect if you apply to increase your coverage under the Hospital Benefit.
Where a pensioner applies to cover a common-law spouse, and a new contribution rate is payable (i.e., if you must increase your coverage from "single" to "family"), new coverage can only become effective from the first day of the fourth month following receipt of the application, regardless of when the application is made.
You should note that, given the voluntary nature of the Supplementary coverage, you have three primary responsibilities to fulfil:
you are responsible for ensuring that you have applied for the coverage you wish to have for yourself and your dependants;
you are responsible for examining your pension statement periodically to ensure that any contributions being deducted properly reflect the level of hospital coverage for which you have applied; and
you are responsible for amending your coverage to delete any coverage you no longer require. Contributions which you have paid are not refunded if they were consistent with the applications you had submitted.
If, as a pensioner, you will be residing outside Canada and you are not eligible for coverage under a provincial health plan, you are eligible only for Comprehensive coverage. The terms which will apply are described in the following paragraphs, and you should consult your pension office if you need further clarification.
If you decide to become covered for the benefits described above you may also apply for additional hospital coverage under Level II or Level III of the Hospital Benefit.
As a pensioner residing outside Canada without provincial health plan coverage, you may wish to apply for a combination of coverage which consists of the Basic Health Care Benefit, plus the Extended Health Care Benefit. You are also covered automatically for Level I coverage under the Hospital Benefit, with the government paying the full contribution for Level I on your behalf. You may choose not to enrol in the plan at all, but if you do join, you may not choose the Hospital Benefit without the Basic Health Care Benefit and the Extended Health Care Benefit.
|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.|
Since the coverage described above is available on a strictly voluntary basis, it is your responsibility to make sure that you obtain the level of coverage you require and that you have covered your dependants to the extent that you desire. The terms and conditions described under the heading Conditions of Membership will apply.
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.
When you incur charges for a particular eligible service or product, the plan covers only those amounts considered "reasonable and customary". The Administrator will determine what the general level of charges for any specific service or product is, in the locale where the expense is incurred. Published fee guides of associations of practitioners will be consulted for that purpose, where applicable. Any portion of an expense in excess of that "reasonable and customary" amount will not be covered under the plan.
Some of the eligible expenses under the Health Care Plan are subject to specific limits. These limits are set out either in the explanation of the benefits, or in the Table of Maximum Eligible Expenses (see Appendix A). Any expenses you incur which exceed those limits will not be covered under the plan. Changes to these amounts will be announced to members of the plan through their pension offices, and should be noted by each member for future reference.
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.
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.
The Extended Health Care Benefit is comprised of the following benefits:
Vision Care Benefit
Health Practitioners Benefit
Miscellaneous Expense 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.|
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.
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.
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 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:
|anti-anginal agents||anticholinergic preparations|
|antiparkinsonism agents||anti-arrhythmic agents|
|antihyperlipidemic agents||insulin preparations|
|hyperthyroidism therapy||oral fibrinolytic agents|
|parasympathomimetic agents||potassium replacement therapy|
|tuberculosis therapy||topical enzymatic debriding agents;|
No benefit is payable for:
|Ophthalmologist||means a person licensed to practice ophthalmology.|
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 are the reasonable and customary charges for the following items of expense:
|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:
No benefit is payable for expenses incurred under any of the conditions listed in Appendix B.
|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.|
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.
means a person who, as determined by the Administrator, qualifies as a certified electrologist.
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.
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.
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.
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.
means a doctor of medicine (M.D.) legally licensed to practice medicine.
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.
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 Masters 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.
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:
* requires prescription of a physician
** services of an electrologist require a psychiatrists or psychologists prescription; 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
No benefit is payable for expenses incurred under any of the conditions listed in Appendix B.
|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.|
refers to charges established by provincial dental associations for specified services provided by dentists in their provinces.
The Health Care Plan covers only expenses for specified oral surgical procedures, and for certain dental treatment required as the result of an accident.
Eligible expenses means reasonable and customary charges for the following oral surgical procedures performed by a dentist.
1. cysts, lesions, abscesses
soft tissue lesion
hard tissue lesion
b. excision of cysts
c. excision of benign lesion
d. excision of ranula
e. incision and drainage
intra oral soft tissue
intra osseous (into bone)
f. periodontal abscess
incision and drainage
2. gingival and alveolar procedures
b. flap approach with curettage
c. flap approach with osteoplasty
d. flap approach with curettage and osteoplasty
e. gingival curettage
f. gingivectomy with or without curettage
3. removal of teeth or roots
a. removal of impacted teeth
b. removal of root or foreign body from max. antrum
c. root resection (apiectomy or apicoectomy)
4. fractures and dislocations
a. dislocation temporo-mandibular joint (or jaw)
b. fractures mandible
c. fractures maxillar or malar
open reduction (complicated)
5. other procedures
a. avulsion of nerve supra or infra-orbital
b. frenectomy labial or buccal (lip or cheek)
c. lingual (tongue)
d. repair of antra-oral fistula
e. sialolithotomy simple
f. sialolithotomy complicated
g. sulcus deepening, ridge reconstruction
h. treatment of traumatic injuries
repair of soft tissue lacerations
debridement, repair, suturing
i. torus (bone biopsy)
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 physicians prescription is not required.
No benefit is payable for expenses incurred under any of the conditions listed in Appendix B.
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