Public Service Health Care Plan Directive

Extended Health Provision - Dental Benefit

For: all members

Lower Cost Alternative

When two or more courses of treatment for oral procedure or accidental injury are considered appropriate, the Plan will pay for the lesser of the two treatments.

Eligible expenses mean the reasonable and customary charges for the following services and oral surgical procedures performed by a dentist:

Accidental Injury

The services of a dental surgeon, and charges for dental prosthesis, 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 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 12 months following the accident or, in the case of a dependant child under 17 years of age, before attaining 18 years of age. A physician's prescription is not required. This time limit may be extended if, as determined by the Administrator, the treatment could not have been rendered within the time frame specified.

If a member is covered under the Public Service Dental Plan, the RCMP Dependants Dental Care Plan, or the CF Dependants Dental Care Plan, claims for expenses for accidental injury should first be submitted to the PSHCP.

Oral Surgical Procedures

1. cysts, lesions, abscesses

2. gingival and alveolar procedures

3. removal of teeth or roots

4. fractures and dislocations

5. other procedures

If a member is covered under the Public Service Dental Care Plan, the RCMP Dependants Dental Care Plan, or the CF Dependants Dental Care Plan, claims for expenses for oral surgery should first be submitted to that plan. Any amount not covered by that plan may be submitted to the PSHCP.

Exclusions

No benefit is payable for:

1. expenses incurred under any of the conditions listed under General Exclusions and Limitations in the Plan Provisions;

2. dental expenses, except those specifically provided under Eligible Expenses for treatment of accidental injuries to natural teeth and oral surgical procedures.

Extended Health Provision - Out-of-Province Benefit

For: members with Supplementary Coverage

The Out-of-Province Benefit consists of:

• Emergency Benefit While Travelling
• Emergency Travel Assistance Services
• Referral Benefit

Emergency Benefit While Travelling

The PSHCP covers each participant for up to $100,000 (Canadian) in eligible medical expenses incurred as a result of an emergency while travelling on vacation or on business.

Eligible expenses mean the reasonable and customary charges in excess of the amount payable by a provincial/territorial health insurance plan, if they are required for emergency treatment of an injury or disease which occurs within 40 days from the date of departure from the province/territory of residence.

Eligible expenses are charges for:

1. public ward accommodation and auxiliary hospital services in a general hospital;

2. services of a physician;

3. one way economy air fare for the patient's return to their province/territory of residence. Air fare for a professional attendant accompanying the participant is also included where medically required;

4. medical evacuation, which may include ambulance services, when suitable care, as determined by the Administrator, is not available in the area where the emergency occurred;

5. family assistance benefits up to a combined maximum of $2,500 for any one travel emergency, as follows:

6. return of the deceased in the event of death of a family member. The necessary authorisations will be obtained and arrangements made for the return of the deceased to the province/territory of residence. The maximum payable for the preparation and return of the deceased is $3,000.

Emergency Travel Assistance Services

The PSHCP provides a toll free number which gives participants 24 hour access to a world-wide assistance network. The network will provide:

1. transportation arrangements to the nearest hospital that provides the appropriate care or back to Canada;

2. medical referrals, consultation and monitoring;

3. legal referrals;

4. a telephone interpretation service;

5. a message service for family and business associates; messages will be held for up to 15 days;

6. advance payment on behalf of the participant or a covered dependant for the payment of hospital and medical expenses.

To arrange for advance payment of hospital and medical expenses, the participant must sign an authorisation form allowing the Administrator to recover payment from the provincial/territorial health insurance plan. The participant must reimburse the Administrator for any payment made on his behalf which is in excess of the amount eligible for reimbursement under the provincial/territorial health insurance plan and this Plan.

Assistance services are not available in countries of political unrest. The list of countries, as maintained by the Administrator, will change according to world conditions.

Neither the Administrator nor the company providing the assistance network is responsible for the availability, quality or result of the medical treatment received by the participant or for the failure to obtain medical treatment.

Official Travel Status

Employees required to travel on "official travel status" for government business are covered under the Emergency Benefit While Travelling and the Emergency Travel Assistance Services during the entire period of "official travel status". Although there is no time limit to be on "official travel status", the $100,000 (Canadian) benefit coverage limit still applies.

Referral Benefit

The following items of expense are eligible for reimbursement under the PSHCP provided that the services are:

Eligible expenses under this benefit will be limited to the reasonable and customary charges in excess of the amount payable by a provincial/territorial health insurance plan and to the maximum eligible expense specified in the Summary of Maximum Eligible Expenses:

1. public ward accommodation and auxiliary hospital services in a general hospital;

2. services of a physician or surgeon;

3. laboratory services including those services which when ordered by and performed under the direction of a physician provide information used in the diagnosis or treatment of disease or injury. Services include, but are not limited to, blood or other body fluid analysis, clinical pathology, radiological procedures, ultrasounds, etc.

Exclusions

No benefit is payable for:

1. expenses incurred outside the participant's province/territory of residence if they are required for the emergency treatment of an injury or disease which occurred more than 40 days after the date of departure from the province/territory of residence, except as provided for members who are on official travel status;

2. expenses incurred by a participant who is temporarily or permanently residing outside Canada;

3. expenses for the regular treatment of an injury or disease which existed prior to the participant's departure from their province/territory of residence;

4. expenses incurred under any of the conditions listed under General Exclusions and Limitations in the Plan Provisions.

Hospital Provision

For: all members

This provision provides reimbursement for reasonable and customary charges, up to specified amounts, for each day of hospital confinement for the cost of hospital room and board charges other than standard ward charges (i.e., semi-private or private accommodation), whether the member is residing in Canada or outside Canada. There is a maximum amount which may be payable under this provision for each day of confinement, depending on the level of coverage the member has chosen. The levels are shown in the summary of Maximum of Eligible Expenses. All members of the PSHCP must be covered under one level of the Hospital Provision.

Eligible Expenses

Level I, II and III

1. Eligible expense for all participants (other than pensioners residing outside Canada) are charges for semi-private or private hospital room and board charges in excess of the charges for public ward up to the maximum specified in the Summary of Maximum Eligible Expenses for each day of hospitalisation, excluding hospital charges referred to as coinsurance charges or user fees.

2. Eligible expenses for pensioners residing outside Canada are hospital charges up to the maximum specified in the Summary of Maximum Eligible Expenses for each day of hospitalisation.

3. No deductible or co-payment applies.

Exclusions

No benefit is payable for:

1. expenses incurred under any of the conditions listed under General Exclusions and Limitations in the Plan Provisions;

2. co-insurance charges or similar charges for hospital care which are in excess of charges payable by a provincial or territorial government health or hospital insurance plan, except charges as provided under the terms of the hospital provision. However, co-insurance charges for a chronic care hospital for a patient who is confined to a chronic care hospital, and has made at least one claim for such charges before September 1, 1992 and makes a further claim for the same period of confinement, are eligible;

3. personal charges such as televisions and telephones.

Basic Health Care Provision

For: all members with Comprehensive Coverage

The provision is available only to members who reside outside Canada and are not covered under a provincial/territorial health insurance plan. Its purpose is to provide reimbursement for services, excluding Hospital Services, which are the equivalent as far as possible to those services available to individuals residing in Canada and covered under a provincial/territorial health insurance plan. The co-payment and deductible amount do not apply under this provision.

The maximum eligible expense for these services is equal to a multiple of the amount otherwise payable based on the current fee schedule in force under the Health Insurance Act 1972 of Ontario on the day when the expense is incurred. The multiple is specified in the Summary of Maximum Eligible Expenses.

Eligible Expenses

The eligible expenses include:

1. services of a physician including:

2. services of an optometrist;

3. services of a physiotherapist;

4. ambulance services;

5. services of a chiropractor, osteopath or podiatrist.

Exclusions

No benefit is payable for:

1. expenses incurred under any of the conditions listed under General Exclusions and Limitations in the Plan Provisions.

2. physician services rendered as a salaried employee of a hospital. An employee posted outside Canada may be reimbursed for these expenses under the Hospital (Outside Canada) Provision.

Hospital (Outside Canada) Provision

For: - all employees with Comprehensive Coverage
- not available to pensioners

Coverage under this provision is mandatory for employees and members of the CF and RCMP residing outside Canada who are not eligible to be covered under a provincial/territorial health insurance plan. Its purpose is to provide hospital coverage protection equivalent, as far as possible, to that available to individuals resident in Canada and covered under a provincial/territorial health or hospital plan. This provision provides reimbursement for reasonable and customary charges for hospital confinement in a general hospital, a hospital of the Canadian Forces or a hospital of the armed forces of a foreign country. The co-payment and deductible amounts do not apply under this Provision.

Eligible Expenses

Eligible expenses are hospital charges for each day of hospitalisation in a general hospital, a hospital of the CF or the forces of a foreign country.

Eligible charges may include those for:

1. standard ward accommodation;

2. necessary nursing services when provided by the hospital;

3. laboratory, radiological and other diagnostic procedures;

4. drugs, prescribed and administered in hospital by any attending physician;

5. use of operating and delivery rooms, anaesthetic and surgical supplies;

6. services rendered by any person paid by the hospital;

7. use of speech therapy facilities when prescribed by a physician;

8. use of diet counselling services when prescribed by a physician;

9. out-patient services provided by a hospital.

Exclusions

No benefit is payable for:

1. expenses incurred under any of the conditions listed under General Exclusions and Limitations in the Plan Provisions;

2. co-insurance charges or similar charges for hospital care which are in excess of charges payable by a provincial or territorial government health or hospital insurance plan and which are not charges made for utilisation of semi-private or private accommodation, except that co-insurance charges for a chronic care hospital for a patient who is confined to a chronic care hospital, and has made at least one claim for such charges before September 1, 1992 and makes a further claim for the same period of confinement, are eligible;

3. a person insured under a non-government group hospital insurance plan administered in a foreign country that provides hospital expense benefits similar to those provided under the Health Insurance Act, 1972 of Ontario, as amended from time to time.

Summary of Maximum Eligible Expenses

Length of time a prescription is valid

Schedule I - Participating Employers

List of participating employers subject to the PSHCP, as amended from time to time by the Treasury Board of Canada:

Schedule II - Employers Withdrawn from the PSHCP

The following commissions, boards or agencies were designated by the Treasury Board of Canada as having withdrawn from the PSHCP on the date specified, as amended from time to time by the Treasury Board of Canada: