The PSHCP Bulletin is produced by the Public Service Health Care Plan
(PSHCP) Trust
November 2005
What is Changing in Your Provincial/Territorial Healthcare Plan?
Changes to provincial/territorial healthcare plans sometimes affect the
expenses you might submit to the PSHCP. In this issue, we describe the recent
modifications to those plans announced by a few provinces. For your reference,
we have also summarized the changes introduced this year and in 2004. We have
grouped the changes by province, and where applicable, we have indicated how
your PSHCP benefit has been impacted.
Please remember that if you are entitled to benefits under a provincial/
territorial plan, you must first submit your claims to that plan before
submitting your claim to the PSHCP for the remaining expenses, if eligible.
Ontario
Effective November 1, 2004
Vision Care – OHIP removed coverage for eye exams for residents aged
20 to 64 but maintained coverage for children under 20 and seniors older than
age 64, as well as high-risk individuals (residents of any age that have been
diagnosed with a medical condition or a specific disease of the eye). The PSHCP
continues to cover the reasonable and customary charges for one eye examination
by an optometrist every two calendar years, commencing every odd year, payable
at 80%.
Chiropractic Services – These services are no longer covered under
OHIP. Chiropractic claims can be submitted to the PSHCP as our Plan considers
eligible chiropractors' expenses up to a maximum of $500 per calendar year,
payable at 80%.
Physiotherapy – The OHIP coverage was amended to limit these
services to individuals that reside in a long-term care facility or are
receiving home care. Previously, physiotherapy services were only covered in
approved clinics to a maximum of $150 per benefit year.
Effective April 1, 2005
Physiotherapy – The Province of Ontario once again modified its
coverage for physiotherapy services. These are now eligible for OHIP coverage
for people who:
- Are 65 years of age or older, to a maximum of 100 visits per year;
- Are under 19 years of age, to a maximum of 100 visits per year;
- Reside in a long-term care facilities at any age;
- Require physiotherapy in their home or after being hospitalized at any age to a maximum of 50 visits;
- Receive the Ontario Disability Support Program, Family Benefits or Ontario Works at any age.
Under the medical practitioners benefit, the PSHCP continues to cover the
reasonable and customary charges for services of a physiotherapist. You are
entitled to claim the first $500 of expenses as well as charges over $1000 per
calendar year, payable at 80%, if these services are prescribed by a physician.
Manitoba
Effective April 1, 2005
Pharmacare Deductible – The family
Pharmacare deductible was increased by 5% in 2004 and again in 2005 based on a
percentage of income. Please note that this is applicable to drugs only, and as
has been the practice in the past, you can continue to submit the unpaid
expenses to the PSHCP.
Circumcision – As mentioned in the PSHCP Bulletin issued in
June 2005, the province of Manitoba also ceased coverage for circumcision of
newborns, unless medically required. As this service is no longer covered by any
provincial/territorial health insurance plan, the PSHCP no longer provides
coverage for routine circumcision of newborns.
Alberta
Effective April 1, 2004
Cryosurgery of the Prostate – As mentioned in the previous PSHCP
Bulletin, under the medical practitioner's clause, the Plan is now covering the
physician's fees portion of expenses for cryosurgery of the prostate since
Alberta Health Care has decided to cover these services when certain medical
conditions exist.
Effective July 1, 2005
Chiropractic and Podiatry – The Alberta government introduced changes to
chiropractic and podiatry coverage that will now allow group benefit plans to
reimburse plan members for incurred expenses from the date that the initial
services are provided. As you incur expenses, you may now submit the portion not
covered by your provincial plan to the PSHCP.
Effective September 1, 2005
Hospital Coverage – As part of its planned health policy and regulatory
changes known as the "Third Way", the Alberta government has announced
that each of the province's nine Regional Health Authorities can set their own
rates for semi-private and private hospital rooms. Prior to this change, the
regulation set the room rate at $18 to $24 for semi-private rooms and $24 to $40
for private rooms. This regulation has been revised to remove the maximum
limitations so that each health authority in the province can now set their own
rates. In turn, it is expected that these rates will increase, especially in the
urban areas. The PSHCP will continue to provide for semi-private or private
hospital accommodation based on the coverage level that you have selected.
Information on this benefit can be found under the hospital provision in your
members' booklet.
Quebec
Effective July 1, 2004
RAMQ Universal Drug Program – If you are a resident of Quebec and
participate in the RAMQ Drug Program, the monthly deductible for drugs was
increased from $9.60 to $10.25 and the out-of-pocket maximum was increased from
$839 to $857. The RAMQ reimbursement level was reduced from 72% to 71.5%.
Effective July 1, 2005
Again, if you are a resident of Quebec and participate in the RAMQ Drug
Program, the annual premium increased from $494 to $521, and the monthly
deductible increased from $10.25 to $11.90.
Saskatchewan
Effective July 1, 2004
Maximum Allowable Cost– The Drug Plan implemented a policy called the
Maximum Allowable Cost (MAC) policy. Under the terms of this policy, the price
of the most cost effective drugs will be used as a guide to set the maximum
price that the Drug Plan will cover for other similar drugs used to treat the
same condition. As has been the case in the past, you can continue to submit the
unpaid expenses to the PSHCP.
Internet Services for PSHCP Members
For the past year, PSHCP members have had access to the Group Claims
Information Web site hosted by Sun Life and it has proven to be a useful
tool to obtain benefit information pertaining to the Plan. One of the best
features, among many, is that you can obtain the status of your most recent
claim. You can find out if your claim has been processed and when the Claims
Statement will be available online, or if your claim is still pending. Among
other functions, you can also obtain information on past claims for your records
or find out when you, or your eligible dependants, will be eligible for their
next pair of eyeglasses or contact lenses. To gain access to this website, you
will need an Access ID and Personal Identification Number (PIN) which can be
easily obtained by visiting www.sunlife.ca/member and following the
instructions.
PSHCP Coverage Information
The PSHCP covers a portion of the reasonable and customary expenses for
specific products and services that are not covered by your provincial
healthcare plan. However, there are some products or procedures that it does not
cover, and others have certain conditions that must be met in order to be
eligible. Here are two examples.
Magnetic Resonance Imaging (MRI) is not covered
When an MRI is performed in a hospital setting, the cost is covered by your
provincial plan, and therefore cannot be claimed under the PSHCP. At the current
time, MRI services are also available at the patient's cost in private
clinics in Alberta and Quebec, but neither of these two provincial plans insures
the services as they are not performed in a hospital, nor are they eligible
expenses under the PSHCP. Therefore, if you undergo an MRI in a facility other
than a hospital (i.e. private clinic), you will be responsible for the related
expenses, no matter in which province or territory you reside.
Orthopaedic Shoes?
A Point of Clarification The PSHCP will reimburse the reasonable and
customary cost of orthopaedic shoes only if these are an integral part of a
brace or if they are specially constructed for the patient. This means
that the provider must take a mould of the feet, and from that mould or cast,
build the shoes for that specific individual. The Plan will also cover
modifications to the patient's orthopaedic shoes. To be covered by the Plan,
orthopaedic shoes or modifications to orthopaedic shoes must be prescribed
by a physician or a podiatrist, and the prescription is valid for a period of
one year. The eligible expenses are payable at 80% with a maximum expense of
$150 per calendar year, once the annual deductible has been satisfied.
Shoes that are manufactured for a specific medical condition, such as extra
depth shoes or comfort shoes, are not covered by the Plan as they are not
specifically made for an individual, and can be acquired without a prescription.
New Claim Statements
In an effort to continuously improve the service offered to PSHCP members,
the Plan Administrator has revised the Explanation of Benefits to make it
simpler, more informative and appealing. They have also changed the name from
"Explanation of Benefits" to the simpler "Your Claim
Statement". The new claim statements have also been significantly
restructured so that all details about a claim (i.e. amount claimed, amount paid
by the PSHCP, etc.) will now appear in columns on a single line. This will make
it much easier for you to understand the calculations. A summary is now provided
on the front page and you can quickly see how much is being paid for all
expenses on the statement.
Another significant improvement is that Sun Life's Customer Care Centre will
now have access to an electronic copy (PDF) of the actual paper claim statement
that you receive. This will enable the customer care representative to see
exactly what you are looking at when you call with a question.
Change of Address
You are reminded that it is important to inform either your personnel office
or pension office, whether you are an active employee or a pensioner, of any
change of address. We also require that you indicate any change of address when
submitting a claim to the Plan Administrator. Please note that this
information should not be sent to the PSHCP Trust.
In addition, please note that you should not send your claims to the offices
of the PSHCP Trust. Please ensure to send your health claims to the following
address:
Sun Life Assurance Company of Canada
Health Claims Office
P.O. Box 9601 CSC-T
Ottawa, Ontario K1G 6A1
Return undeliverable Canadian addresses to:
1201-99 Bank Street
Ottawa, ON K1P 5A3
The PSHCP Bulletin is produced by the Public Service Health Care Plan
(PSHCP) Trust to provide you with benefit and administrative information about
your health care plan.
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