Other Related Documents

Foreword

The purpose of this booklet is to provide you with a description of the benefits you are entitled to as a participant of the Public Service Health Care Plan (PSHCP). It is a convenient reference document that outlines the services and products eligible for reimbursement under the terms of the Plan. It also summarizes the key provisions that govern the Plan.

The information contained in this booklet describes the coverage and the Plan provisions, as they exist on July 1, 2001. The Plan may be amended from time to time. Members will receive written official notification of changes to the Plan. Please keep any future Plan change notices with this booklet.

Certain words and terms have a specific meaning in the context of the Plan. These words are italicized whenever they appear in the text, and are defined in the Glossary at the back of the booklet.

This booklet is not a substitute for the Plan Document. The complete terms and conditions of the Plan, as amended from time to time, are set out in the PSHCP Plan Document, Plan number 55555.

You can consult the Plan Document at any time through the Internet on the Treasury Board of Canada website. To obtain the Internet address, or if you do not have access to the Internet, please refer to the For more information section at the end of this booklet.

General

Purpose of the Public Service Health Care Plan (PSHCP)

The purpose of the PSHCP is to reimburse Plan participants for all or part of costs they have incurred for eligible services and products, as identified in the Plan Document, only after they have taken advantage of benefits provided by their provincial/territorial health insurance plan or other third party sources of health care expense assistance to which the participant has a legal right. Unless otherwise specified in the Plan Document, all eligible services and products must be prescribed by a physician or a dentist who is licensed, or otherwise authorised in accordance with the applicable law, to practice in the jurisdiction in which the prescription is made.

The PSHCP reimburses eligible expenses on a reasonable and customary basis to ensure that the level of charges are within reason in the geographic area where the expense is incurred, subject to limitations which are identified in the Plan Document.

Management of the PSHCP

PSHCP Trust

The PSHCP is managed through a Trust having Trustees appointed by the three PSHCP parties.

Financial management

The Plan is 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 PSHCP is funded through contributions from the Treasury Board of Canada, participating employers, and the Plan members in accordance with the Trust Agreement which took effect April 1, 2000, between the Bargaining Agents of the National Joint Council, the Federal Superannuates National Association, and the Treasury Board of Canada (known as the PSHCP parties).

Administration of the PSHCP

Administrator

The Administrator, Sun Life Assurance Company of Canada, is responsible for the consistent adjudication and payment of eligible claims in accordance with the Plan Document and for providing services as specified in the Administrative services only contract.

Commencement, amendment and termination of coverage

Eligibility

The PSHCP applies to Public Service employees, members of the Canadian Forces (CF), members of the Royal Canadian Mounted Police (RCMP), pensioners, and their respective dependants. In the case of the members of the CF and the RCMP, coverage is limited to their eligible dependants.

In general, membership in the Plan is optional. If you are eligible and wish to join the PSHCP or make a change to your coverage, you must complete and submit an application to your Personnel or Pension office. This requirement applies even if you are not required to make a monthly contribution.

When your application to join the Plan has been approved, you will be issued a benefit card showing your Certificate Number and the level of coverage you have chosen. A new benefit card will be issued whenever you amend your coverage.

If you have questions concerning your eligibility, your dependants' eligibility, and your effective date of coverage, or if you wish to obtain the appropriate forms, you should contact your Personnel or Pension office.

Effective date of coverage

When joining the Plan

If you apply within 60 days of becoming eligible, coverage is effective the first of the month following the month your Personnel or Pension office receives your completed application form.

If you do not apply for coverage within 60 days of becoming eligible, the requested coverage will take effect on the first day of the fourth month following the month your Personnel or Pension office receives your completed application.

If you cease to be employed and receive an immediate recognized ongoing pension benefit, coverage continues automatically. You must, however, authorize in writing that the required deductions will be taken from your pension cheque.

When acquiring a dependant

If you wish to amend your coverage from single to family coverage as a result of acquiring a dependant and you submit your application form within 60 days of acquiring your new dependant, coverage will become effective on the date of acquiring your dependant.

If you do not apply to upgrade your coverage from single to family within 60 days of acquiring a dependant, the requested coverage will take effect on the first day of the fourth month following the month your Personnel or Pension office receives your completed application.

When increasing the level of coverage under the Hospital provision

An increase to the level of coverage under the Hospital provision will be effective on the first day of the fourth month following the month your Personnel or Pension office receives your completed application form, unless you are applying to increase your coverage coincident with an application to reduce your PSHCP coverage from family to single.

The three-month waiting period does not apply when the application is received within 60 days of:

• acquiring a dependant,
• ceasing to be covered under a provincial/territorial insurance plan or vice versa and the member wishes to transfer from Supplementary to Comprehensive coverage or vice versa,
• an employee becoming in receipt of a recognized ongoing immediate pension benefit,
• a member of the CF or RCMP or a pensioner becoming employed in the Public Service,
• a survivor or dependant child(ren) of a deceased member becoming in receipt of an ongoing recognized survivor's or children's benefit.

Termination of coverage

A member ceases to be eligible on the date of:

• cessation of employment if they are not in receipt of an immediate recognised ongoing pension benefit,
• becoming an employee locally engaged outside Canada,
• becoming employed in a portion of the Public Service excluded from thePlan, or
• ceasing to receive the disability pension because they have recovered their health.

Voluntary cessation of coverage

A member who wishes to cancel their PSHCP coverage must put their request in writing to the designated officer. Deductions will cease no later than two months following the date notification was received by the designated officer. Coverage will continue for one month following the month that the last deduction was made.

A retroactive cancellation cannot be authorised.

Employees who cancel their coverage at any time while on leave without pay, will not be allowed to reinstate their coverage until they return to duty, at which time a three‑month waiting period will apply.

When cancelling a dependant's coverage, the dependant's coverage ceases no later than two months following the date that the application is received by the designated officer. The deductions at the lower rate start the month prior to the effective date of the new coverage.

Except in case of death of a dependant or of a designated officer not ceasing deductions within two months of receiving an application, no contributions will be refunded when the member cancels their dependant's coverage.

Involuntary cessation of coverage

When a member ceases to be an eligible employee or an eligible pensioner, if a contribution is deducted in the month during which the member ceases to be eligible, coverage of the member and their dependant(s) will continue until the end of the following month.

In the case of a dependant's death, the contributions are adjusted effective the month of death of the dependant, provided the application is received by the designated officer within 60 days of death. If the application is received after 60 days, contributions are adjusted effective the first of the month following receipt of the application by the designated officer.

Contributions

The PSHCP is supported through contributions from the Treasury Board of Canada, participating employers and Plan members.

Monthly contributions from members, where applicable, are payable one month in advance of the effective date of coverage. They are deducted from salary or a recognized pension, survivor's or children's benefit, as authorized in writing by the member.

Whenever changes are made to the contribution rates, you will be informed by your Personnel or Pension office. You should periodically ensure that the correct monthly contributions are being deducted from your salary or pension.

Active members who proceed on authorized leave without pay (LWOP) or on seasonal lay-off may continue their coverage and that of their dependants by paying the required contributions, in advance, to their Personnel office by cheque or money order made payable to the Receiver General for Canada. Members must contact their Personnel office, before proceeding on leave, regarding the requirement to make contributions for continued coverage.

Available coverage

Supplementary coverage

This coverage is intended for eligible participants who are covered under a provincial/territorial health insurance plan. In general, the PSHCP supplements the coverage provided under the provincial/territorial plan in the member's province/territory of residence.

This coverage consists of the:

• Extended health provision (80% reimbursement/deductible except for the Emergency benefit while travelling and the Emergency travel assistance services which are reimbursed at 100% and no deductible applies),
• Hospital provision (100% reimbursement/no deductible).

Comprehensive coverage

This coverage is intended for members and their eligible dependants who are residing with the member outside Canada and who are not covered under a provincial/territorial health insurance plan or in a non-government hospital insurance plan. A person covered under Comprehensive coverage will continue to be covered under this benefit after their return to Canada until such time as they become eligible to be insured under a provincial/territorial health insurance plan.

This coverage consists of the:

• Extended health provision (80% reimbursement/deductible) except for the Out‑of‑province benefit which is not available under Comprehensive coverage,
• Hospital provision (100% reimbursement/no deductible),
• Basic health care provision (100% reimbursement/no deductible),
• Hospital expense (outside Canada) provision (100% reimbursement/no deductible). This provision does not apply to pensioners.

Please note, employees who reside outside Canada (e.g. USA) but work inCanada, are not entitled to comprehensive coverage.

Employees and members of the CF or RCMP posted outside Canada

If you are a member of this category, you are required by your employer to be covered for Comprehensive coverage. If your dependants are residing with you outside Canada, you are also required to obtain Comprehensive coverage for those dependants.

Coverage is also available, on a voluntary basis, for certain persons other than your dependants who reside with you and are financially dependent upon you. You should consult your Personnel office if you are interested in these benefits.

You may also opt to upgrade your coverage and apply for additional hospital coverage under Level II or Level III of the Hospital provision.

Employees and members of the CF or RCMP on loan to serve with an international organization or on an authorized educational leave without pay outside Canada

If you are a member of this category, you are eligible for coverage provided under the Comprehensive coverage provision. If you apply for benefits, you will be covered automatically under the Extended health provision (except for the Out‑of‑province benefit), the Basic health care provision, Level I coverage under the Hospital provision, and the Hospital expense (outside Canada).

You may also opt to upgrade your coverage and apply for additional hospital coverage under Level II or Level III of the Hospital provision.

Pensioners residing outside Canada

As a pensioner residing outside Canada without provincial/territorial health plan coverage, you may wish to apply for the benefits provided by the Comprehensive coverage. If you apply for benefits, you will be covered automatically under the Extended health provision (except for the Out‑of‑province benefit), the Basic health care provision and for Level 1 coverage under the Hospital provision. It is important to note that the Hospital expense (outside Canada) provision is not available to pensioners residing outside Canada.

You may also opt to upgrade your coverage and apply for additional hospital coverage under Level II or Level III of the Hospital provision.

Eligibility for coverage

The coverage to which you are entitled depends on where you reside and whether you are covered by a government health insurance plan.

General exclusions and limitations

No benefit is payable for:

• expenses for which benefits are payable under a Workers' Compensation Act or a similar statute or enactment, or by any government agency,
• expenses for services and supplies, rendered or prescribed by a person who is ordinarily a resident in the patient's home or who is related to the patient by blood or marriage,
• expenses for services or products for cosmetic purposes only, or for conditions not detrimental to health, except those required as a result of accidental injury,
• expenses for services or products normally rendered without charge,
• expenses for services rendered in connection with medical examinations for insurance, school, camp, association, employment, passport or similar purposes,
• expenses for services provided by a physician licensed and practising in Canada where the participant is eligible to be insured under a provincial/territorial health insurance plan, except for such services which are specifically included under the section entitled Plan provisions,
• expenses for experimental products or treatments, for which substantial evidence provided through objective clinical testing of the product's or treatment's safety and effectiveness for the purpose and under the conditions of the use recommended does not exist to the Administrator's satisfaction,
• expenses for benefits which are legally prohibited by a government from coverage,
• the portion of charges which are payable under a provincial/territorial health insurance plan, a provincial/territorial drug plan, or any provincially/territorially sponsored program, whether or not the participant is participating in the Plan or program,
• the portion of charges for services rendered or supplies provided in a hospital outside of Canada, that would normally be payable under a provincial/territorial health or hospital insurance plan if the services or products had been rendered in a hospital in Canada. This limitation does not apply to the eligible expenses under the Hospital (outside Canada) provision and the Extended health provision – Out-of-province benefit,
• the portion of charges which is the legal liability of any other party,
• specific exclusions identified under each Plan benefit.

Extended health provision

The purpose of this provision is to provide coverage for specified services and products which are not covered under provincial/territorial health insurance plans, or alternatively, in the case of members resident outside Canada, which are not covered under the Basic health care provision of the PSHCP. All members of the PSHCP are covered under this provision, except for those with Comprehensive coverage who are not eligible for the Out-of-province benefit.

The Extended health provision is comprised of the following benefits:

• Drug benefit
• Vision care benefit
• Medical practitioners benefit
• Miscellaneous expense benefit
• Dental benefit
• Out-of-province benefit (for members with Supplementary coverage only)
• Emergency benefit while travelling
• Emergency travel assistance services
• Referral benefit

Some of the aforementioned benefits may be subject to reasonable and customary charges, and to certain limits as specified in the Summary of maximum eligible expenses. All are subject to deductible and co-payment except for the Emergency benefit while travelling and the Emergency travel assistance services.

Drug benefit

To be eligible, expenses must be:

• the reasonable and customary charges,
• prescribed by a physician
• or dentist, and
• dispensed by a pharmacist or physician.

Eligible expenses

Eligible expenses are:

• drugs which legally require a prescription and are identified in the Monographs section of the current Compendium of pharmaceuticals and specialities as a narcotic, controlled drug, or requiring a prescription, except for those specified under Exclusions listed in this section,
• life-sustaining drugs which may not legally require a prescription and are identified in Schedule VII of the Plan Document,
• 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 participant,
• injectable drugs, including allergy serums administered by injection,
• compounded prescriptions, regardless of their active ingredients,
• 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,
• drug delivery devices to deliver asthma medication, which are integral to the product, and approved by the Administrator,
• aerochambers with masks for the delivery of asthma medication, provided the patient is a dependant child under 6 years of age,
• specialised formulas for infants with a confirmed intolerance to both bovine and soy protein. The attending physician must confirm in writing that the infant cannot tolerate any other formula or feeding substitute,
• smoking cessation aids limited to the maximum eligible expense specified in the Summary of maximum eligible expenses.

Exclusions

No benefit is payable for:

• Viagra (Sildenafil citrate),
• expenses for drugs which, in the Administrator's opinion, are experimental,
• publicly advertised items or products which, in the Administrator's opinion, are household remedies,
• expenses for contraceptives, other than oral,
• expenses for vitamins (except injectables), minerals, and protein supplements, other than expenses that would qualify for reimbursement under Eligible expenses,
• expenses for therapeutic nutrients other than those that would qualify for reimbursement under Eligible expenses,
• expenses for diets and dietary supplements, infant foods and sugar or salt substitutes, other than expenses that would qualify for reimbursement under Eligible expenses,
• expenses for lozenges, mouth washes, non-medicated shampoos, contact lens care products and skin cleansers, protectives or emollients,
• expenses for drugs which are used for cosmetic purposes,
• expenses for drugs which are used for a condition or conditions not recommended by the manufacturer of the drugs,
• expenses incurred under any of the conditions listed under General exclusions and limitations (page 10),
• expenses which are payable under a provincial/territorial drug plan whether or not the participant is participating in the Plan.

Vision care benefit

Eligible expenses

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

• eye examinations by an optometrist limited to the maximum eligible expense specified in the Summary of maximum eligible expenses,
• 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 the Summary of maximum eligible expenses,
• the initial purchase of intraocular lenses, eyeglasses or contact lenses that are necessary for the correction of vision and required as a direct result of surgery or an accident where the purchase is made within six months of such accident or surgery. This benefit is not subject to any limits other than reasonable and customary. The six-month time limit may be extended if, as determined by the Administrator, the purchase could not have been made within the time frame specified,
• artificial eyes and replacements thereof but not within:
  • 60 months of the last purchase in the case of a member or dependant over 21 years of age, or
  • 12 months of the last purchase in the case of a dependant 21 years of age or less,

unless medically proven that growth or shrinkage of surrounding tissue requires replacement of the existing prosthesis.

Exclusions

No benefit is payable for:

• laser eye surgery to correct vision so that visual aids such as glasses or contact lenses will no longer be required. This would include but not be limited to, procedures such as eximer laser, photo refractive keratectomy (PRK), lasik,
• expenses incurred under any of the conditions listed under General exclusions and limitations (page 10).

Medical practitioners benefit

Eligible expenses for the services of a medical practitioner include only those services that are within their area of expertise and require the skills and qualifications of such a medical practitioner. In addition, in accordance with provincial/territorial regulations, the medical practitioner must be registered, licensed, or certified to practise in the jurisdiction where the services are rendered.

Eligible expenses

Eligible expenses are the reasonable and customary charges for:

• physician's services and laboratory services where such services are not eligible for reimbursement under the participant's provincial/territorial health insurance plan, but where such services would be eligible for reimbursement under one or more other provincial/territorial health insurance plans.
  
  Laboratory services include 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.
  
  Where only one province/territory provides reimbursement for a particular service, and that province/territory discontinues the coverage, the issue shall be subject to review by the Trustees as to whether coverage will also be discontinued under the Plan. Claims for such services, following cessation of provincial/territorial coverage, shall be held by the Administrator pending the decision of the Trustees.
  
  Where a province/territory begins reimbursement for a particular service, claims for the service shall be held by the Administrator pending a review by the Trustees as to whether the service should be covered in the other provinces and territories.
  
  
• acupuncture treatments performed by a physician,
• medically necessary private duty and visiting nursing services provided by a nurse graduated from a recognised school of nursing where such services are prescribed by a physician and are rendered in the patient's private residence, subject to the maximum eligible expense specified in the Summary of maximum eligible expenses. The prescription is valid for one year unless otherwise advised by the Administrator,
• the services of the following practitioners, limited to the maximum eligible expense specified in the Summary of maximum eligible expenses for each practitioner:
  • physiotherapist (the prescription* is valid for one year),
  • massage therapist (the prescription* is valid for six months),
  • speech language pathologist (the prescription* is valid for one year),
  • psychologist (the prescription* is valid for one year),
  • chiropractor,
  • osteopath,
  • naturopath,
  • podiatrist or chiropodist,
  • electrologist* or physician when performing electrolysis treatments, limited to:
    • treatment for the permanent 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,
    • in the case where the services are performed by an electrologist, a prescription is required from a psychiatrist or a psychologist to certify that the patient suffers from severe emotional trauma as a result of this condition,
    • the prescription is valid for three years.
      
      *  physician's prescription is required.
• utilisation fees for paramedical services which are imposed by the government under the provincial/territorial health insurance plan in the person's province/territory of residence, where the law permits a person to be reimbursed for such charges,
• Prostatic Specific Antigen (PSA) test used for monitoring following the detection of cancer.

Exclusions

No benefit is payable for:

• expenses incurred under any of the conditions listed under General exclusions and limitations (page 10),
• expenses for surgical supplies and diagnostic aids,
• Prostatic Specific Antigen (PSA) test used for screening purposes.

Miscellaneous expense benefit

To be eligible, the expenses must be:

• reasonable and customary charges, and
• prescribed by a physician, unless otherwise specified.

Eligible expenses

Eligible expenses are:

• licensed ground ambulance service to the nearest hospital equipped to provide the required treatment when the physical condition of the patient prevents the use of another means of transportation, where medically necessary,
• emergency air ambulance service to the nearest hospital equipped to provide the required treatment when the physical condition of the patient prevents the use of another means of transportation,
• orthopaedic shoes, which are an integral part of a brace or are specially constructed for the patient, including modifications to such shoes, provided the shoes or modification is prescribed in writing by a physician or podiatrist, limited to a maximum total eligible expense in any one calendar year as specified in the Summary of maximum eligible expenses; the prescription is valid for one year,
• orthotics and repairs to them, prescribed in writing by a physician or podiatrist, limited to one pair in a calendar year; the prescription is valid for three years,
• hearing aids and repairs to them, excluding batteries, limited to the maximum eligible expense equal to the lesser of:
  • cost less the cost of all eligible hearing aid claims made in the previous 5 years, and
  • the maximum specified in the Summary of maximum eligible expenses,
• the initial purchase of hearing aids if required as a direct result of surgery or an accident where the purchase is made within six months of such accident or surgery. This benefit is not subject to any limits other than reasonable and customary. The six-month time limit may be extended if, as determined by the Administrator, the purchase could not have been made within the time frame specified,
• trusses, crutches, splints, casts and cervical collars,
• braces, including repairs, which contain either metal or hard plastic, excluding dental braces and braces used primarily for athletic use,
• orthopaedic brassieres, limited to the maximum eligible expense specified in the Summary of maximum eligible expenses,
• breast prosthesis following mastectomy and a replacement provided 24 months have elapsed since the last purchase,
• wigs, once in a lifetime, when the patient is suffering from total hair loss as the result of an illness, limited to the maximum eligible expense specified in the Summary of maximum eligible expenses,
• colostomy, ileostomy and tracheostomy supplies,
• catheters and drainage bags for incontinent, paraplegic or quadriplegic patients,
• temporary artificial limbs,
• permanent artificial limbs, to replace temporary artificial limbs, and replacements thereof but not within:
  • 60 months of the last purchase in the case of a member or dependant over 21 years of age, or
  • 12 months of the last purchase in the case of a dependant 21 years of age or less,

unless medically proven that growth or shrinkage of surrounding tissue requires replacement of the existing prosthesis,

• oxygen and its administration,
• needles, syringes, and chemical diagnostic aids for the treatment of diabetes, except needles and syringes are not eligible for the 36‑month period following the date of purchase of an insulin jet injector device,
• one insulin jet injector device for insulin dependent diabetics, limited to the maximum eligible expense specified in the Summary of maximum eligible expenses,
• insulin pumps and associated equipment for insulin dependent diabetics, when prescribed for a patient by a physician associated with a recognised centre for the treatment of diabetes at a university teaching centre in Canada, excluding repair or replacement during the 60‑month period following the date of purchase of such equipment,
• blood glucose monitors for insulin dependent diabetics, and for non-insulin dependent diabetics if legally blind or colour blind, excluding repair or replacement during the 60‑month period following the date of purchase of such equipment,
• rental or purchase at the Administrator's option, of cost-effective durable equipment:
  • manufactured specifically for medical use,
  • for use in the patient's private residence,
  • approved by the Administrator for cost effectiveness and clinical value,
  • designated as medically necessary, and
  • used either for care including, but not limited to:
    • devices for physical movement such as:
      • walkers — limited to one every 5 years and a maximum eligible expense equal to cost less all eligible walker repair expenses incurred during the previous 5 years,
      • lifts or hoists — limited to one in a lifetime and a maximum eligible expense equal to cost less all eligible lift/hoist repairs incurred prior to purchase,
      • wheelchairs — limited to one every 5 years and a maximum eligible expense equal to cost less all eligible wheelchair repairs incurred during the previous 5 years,
    • devices for support and resting such as:
      • hospital beds — limited to one in a lifetime and a maximum eligible expense equal to cost less all eligible hospital bed repairs incurred prior to purchase,
      • roho cushions — limited to one every 12 months and a maximum eligible expense of cost less all eligible roho cushion repairs incurred during the previous 12 months,
      • therapeutic mattresses — limited to one every 5 years and a maximum eligible expense equal to cost less all eligible therapeutic mattress repairs incurred during the previous 5 years,
    • devices for monitoring such as:
      • apnea monitors — limited to one in a lifetime and a maximum eligible expense equal to cost less all eligible apnea monitor repairs incurred prior to purchase,
      • enuresis monitors — limited to one in a lifetime and a maximum eligible expense equal to cost less all eligible enuresis monitor repairs incurred prior to purchase,
• for treatment including, but not limited to:
  • devices for mechanical and therapeutic support such as:
    • transcutaneous electric stimulators (TENS) — limited to one every 10 years and a maximum eligible expense equal to cost less all eligible TENS repairs incurred during the previous 10 years,
    • traction kits — limited to one in a lifetime and a maximum eligible expense equal to cost less all eligible traction kit repairs incurred prior to purchase,
    • infusion pumps — limited to one every 5 years and a maximum eligible expense equal to cost less all eligible infusion pump repairs incurred during the previous 5 years,
    • extremity pumps (lymphapress) — limited to one in a lifetime and an eligible expense equal to cost less all eligible extremity pump repairs incurred prior to purchase,
  • devices for aerotherapeutic support such as:
    • CPAP's, BiPAP's and related dental appliances (where a CPAP or BiPAP cannot be tolerated) — limited to one every 10 years and a maximum eligible expense equal to cost less all eligible CPAP, BiPAP or dental appliance repairs incurred during the previous 10 years,
    • compressors — limited to one every 5 years and a maximum eligible expense equal to cost less all eligible compressor repairs incurred during the previous 5 years,
    • maximists — limited to one every 5 years and a maximum eligible expense equal to cost less all eligible maximist repairs incurred during the previous 5 years,

Reimbursement related to durable equipment will be limited to the cost of non-motorised equipment unless medically proven that the patient requires motorised equipment.

• bandages and surgical dressings required for the treatment of an open wound or ulcer,
• elasticised support stockings manufactured to individual patient specifications or having a minimum compression of 30 millimetres,
• elasticised apparel for burn victims,
• penile prosthesis implants.

Exclusions

No benefit is payable for:

• expenses for items purchased primarily for athletic use,
• expenses for ambulance services for a medical evacuation which are eligible under the Out-of-province benefit,
• expenses incurred under any of the conditions listed under General exclusions and limitations (page 10),
  • durable equipment that is:
  • an accessory to an eligible device,
  • a modification to the patient's home (bar, ramp, mat, elevator, etc.),
  • used for diagnostic or monitoring purposes except as specifically provided under Eligible expenses,
  • an implant, except as specifically provided under Eligible expenses,
  • bathroom safety equipment, or
  • an air conditioner,
• ongoing supplies associated with durable equipment,
• durable equipment that is used to prevent illness, disease or injury,
• the use of a device for a treatment which in the Administrator's opinion is considered to be clinically experimental,
• the portion of charges which are payable under a provincial/territorial health insurance plan, or any provincially/territorially sponsored program whether or not the participant is participating in the plan or program.

Dental benefit

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 Care Plan, the RCMP Dependants Dental Care Plan, the CF Dependants Dental Care Plan or the Pensioners' Dental Services 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. Claims for expenses for accidental injury should first be submited to the PSHCP.

Oral surgical procedures

• cysts, lesions, abscesses
  • biopsy
    • soft tissue lesion
    • incision
    • excision
    • hard tissue lesion
  • excision of cysts
  • excision of benign lesion
  • excision of ranula
  • incision and drainage
    • intra oral — soft tissue
    • intra osseous (into bone)
  • periodontal abscess
    • incision and drainage
• gingival and alveolar procedures
  • alveoplasty
  • flap approach with curettage
  • flap approach with osteoplasty
  • flap approach with curettage and osteoplasty
  • gingival curettage
  • gingivectomy with or without curettage
  • gingivoplasty
  • removal of teeth or roots
• removal of impacted teeth
  • removal of root or foreign body from maxillary antrum
  • root resection (apiectomy or apicoectomy)
    • anterior teeth
    • bicuspids
    • molars
• fractures and dislocations
  • dislocation — temporo-mandibular joint (or jaw)
    • closed reduction
    • open reduction
  • fractures — mandible
    • no reduction
    • closed reduction
    • open reduction
    • fractures — maxillar or malar
    • no reduction
    • closed reduction
    • open reduction
    • open reduction (complicated)
    • other procedures
    • avulsion of nerve — supra or infra-orbital
    • frenectomy — labial or buccal (lip or cheek)
    • lingual (tongue)
    • repair of antro-oral fistula
    • sialolithotomy — simple
    • sialolithotomy — complicated
    • sulcus deepening, ridge reconstruction
    • treatment of traumatic injuries
      • repair of soft tissue lacerations
      • debridement, repair, suturing
    • torus (bone biopsy)

Exclusions

No benefit is payable for:

• expenses incurred under any of the conditions listed under General exclusions and limitations (page 10),
• dental expenses, except those specifically provided under Eligible expenses for treatment of accidental injuries to natural teeth and oral surgical procedures.

Out-of-province benefit

The Out-of-province benefit consists of:

• Emergency benefit while travelling
• Emergency travel assistance services
• Referral benefit

and is for members with Supplementary coverage only.

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

Eligible expenses are charges for:

• public ward accommodation and auxiliary hospital services in a general hospital,
• services of a physician,
• one way economy airfare for the patient's return to their province/territory of residence. Airfare for a professional attendant accompanying the participant is also included where medically required,
• 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,
• family assistance benefits up to a combined maximum of $2,500 for any one travel emergency, as follows:
  • the maximum payable for dependant children under age 16 who are left unattended because the participant or the participant's covered spouse is hospitalised and an escort (if necessary) is the cost of economy airfare for return transportation,
  • return transportation if a family member is hospitalised and as a result the family members are unable to return home on the originally scheduled flight, and must purchase new return tickets. The extra cost of the return airfare is payable, to a maximum of the cost of economy airfare,
  • a visit of a relative if the family member is hospitalised for more than 7 days while travelling alone. This includes economy airfare, and meals and accommodations to a maximum of $150 per day, for a spouse, parent, child, brother or sister. This benefit also covers expenses incurred if it is necessary to identify a deceased family member prior to release of the body,
  • meals and accommodations if the participant or a covered dependant's trip is extended due to hospitalisation of a family member. The additional expenses incurred by accompanying family members for accommodations and meals are provided to a maximum of $150 per day,
• 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:

• transportation arrangements to the nearest hospital that provides the appropriate care or back to Canada,
• medical referrals, consultation and monitoring,
• legal referrals,
• a telephone interpretation service,
• a message service for family and business associates; messages will be held for up to 15 days,
• 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 their behalf which is in excess of the amount eligible for reimbursement under the provincial/territorial health insurance plan and the PSHCP.

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:

• performed when the participant physically leaves the province/territory of residence,
• following a written referral by the attending physician in the province/territory of residence,
• for a service that is not offered in the province/territory of residence.

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:

• public ward accommodation and auxiliary hospital services in a general hospital,
• services of a physician or surgeon,
• 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:

• 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,
• expenses incurred by a participant who is temporarily or permanently residing outside Canada,
• expenses for the regular treatment of an injury or disease which existed prior to the participant's departure from their province/territory of residence,
• expenses incurred under any of the conditions listed under General exclusions and limitation.

Hospital provision

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. The co‑payment and deductible amount do not apply under this provision.

Eligible expenses

Eligible expenses are charges for:

• all participants other than pensioners residing outside Canada, 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 co-insurance charges or user fees,
• pensioners residing outside Canada, hospital charges up to the maximum specified in the Summary of maximum eligible expenses for each day of hospitalisation.

Exclusions

No benefit is payable for:

• expenses incurred under any of the conditions listed under General exclusions and limitations (page 10),
• coinsurance charges or similar charges for hospital care which are in excess of charges payable by a provincial/territorial government health or hospital insurance plan and which are not charges made for utilisation of semi-private or private accommodation,
• personal charges such as televisions and telephones.

Basic health care provision

The provision forms part of the Comprehensive coverage and 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:

• services of a physician including:
  • physician's services in the participant's home, the physician's office, clinic or in a hospital,
  • diagnosis and treatment of illness and injury,
  • one annual health examination,
  • treatment of fractures and dislocations,
  • surgery, including surgery performed by a Doctor of podiatric medicine (DPM) when performed in the United States of America,
  • administration of anaesthetics,
  • x-rays for diagnostic and treatment purposes,
  • obstetrical care, including prenatal and postnatal care,
  • laboratory services and clinical pathology when ordered by and performed under the direction of a physician,
• services of an optometrist,
• services of a physiotherapist,
• ambulance services,
• services of a chiropractor, osteopath or podiatrist.

Exclusions

No benefit is payable for:

• expenses incurred under any of the conditions listed under General exclusions and limitations (page 10),
• 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

Coverage under this provision forms part of the Comprehensive coverage and 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. It is, however, not available to pensioners. 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 armed forces of a foreign country.

Eligible charges may include those for:

• standard ward accommodation,
• necessary nursing services when provided by the hospital,
• laboratory, radiological and other diagnostic procedures,
• drugs, prescribed and administered in hospital by any attending physician,
• use of operating and delivery rooms, anaesthetic and surgical supplies,
• services rendered by any person paid by the hospital,
• use of speech therapy facilities when prescribed by a physician,
• use of diet counselling services when prescribed by a physician,
• out-patient services provided by a hospital.

Exclusions

No benefit is payable for:

• expenses incurred under any of the conditions listed under General exclusions and limitations (page 10),
• co-insurance charges or similar charges for hospital care which are in excess of charges payable by a provincial/territorial government health or hospital insurance plan and which are not charges made for utilisation of semi-private or private accommodation,
• 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.