Public Service Health Care Plan: Administrator change includes changes to plan

The Public Service Health Care Plan (PSHCP) is changing administration from Sun Life, following a competitive procurement process that took place at the end of last year by the Government of Canada.

The PSHCP, the healthcare plan for government employees and dependents like military families, will be administered by Canada Life Assurance Company (Canada Life) as of July 1, 2023.

According to the PSHCP Bulletin, “The contract will maintain, and in some areas, surpass, existing PSHCP standards of excellence in claims processing services.The contract ensures high-quality data for decision-making, robust auditing, advanced fraud detection, increased digitization, and improved member communications and services. The new contract will also support the Government of Canada’s policy goals on green procurement, digitization, diversity and inclusion and, in particular, opportunities for Indigenous Canadians.”

No Impact on Existing Users

According to PSHCP, a new plan administrator will have no impact on benefits available to its users, nor will the cost change. The award of the new contract to Canada Life “simply changes who administers the PSHCP and what company processes your claims,” the PSHCP website states.

A comprehensive transition period is taking place until July 1, 2023, to ensure all users’ positive enrolment information is transferred to Canada Life. Until then, recipients are asked to continue to file claims and requests to Sun Life.

What You Need to Know

PSHCP members are asked to keep the following in mind as the transition process takes place over the next year:

• Keep your Positive Enrolment Information up-to-date on the Sun Life Plan Member Services website or app.
• Members will receive regular updates on the transition and might be asked to take a few simple steps.
• The change will not affect deadlines for claims in process or claims submitted after July 1, 2023, for eligible expenses incurred before the transition.

PSHCP Update: New tentative agreement reached

Promoting health & wellness through evidence-based medical care and plan design

• Mental healthcare services when provided by an accredited psychologist, social worker, psychotherapist, or counsellor at to $5000 per year (from $2000). No prescription required. Covered professionals vary by province.
• Glasses/contact lens benefit at $400 every 2 years (from $275)
• Laser eye surgery at $2000 per lifetime (from $1000)
• Increase of the massage, podiatrist/chiropodist benefit to $500 (from $300)
• Smoking cessation coverage at $2000 (from $1000) per lifetime
• New coverage for dieticians, occupational therapists, and lactation consultants at $300 per year

Under the new plan acupuncture is now eligible when performed by a registered acupuncturist at an eligible maximum of $500 per year.

Providing comprehensive coverage to care for members in difficult life situations

• A prior authorization program for a limited number of high-cost drugs to ensure treatment plan is appropriate and cost-effective (new).
• Grandfathering provisions for members currently on affected high-cost drugs.
• Gender affirmation coverage at $75,000 per lifetime (new) and automatic coverage for electrolysis
• Electrolysis at $1200 per year (previously capped per session)
• Wigs at $1500 (from $1000) and coverage for new conditions
• Injectable joint lubricant coverage at $600 (new)
• Naturopath and osteopath coverage at $500 (from $300)
• Footcare performed by a community nurse covered under the podiatrist benefit (new)
• Nursing coverage at $20,000 (from $15,000)
• Speech language at $750 (from $500) and audiologist coverage under this benefit (new)
• CPAP supplies at $500 (from $300)
• Orthopaedic shoes at $250 (from $150)
• Wheelchair coverage within 5 years of last claim when medical condition changes so that a new type of chair is required (new exception)
• New coverage for medically necessary monitors including oxygen saturation meter, pulse oximeter, saturometer, and blood pressure monitor, once every 60 months each
• Coverage and contribution rates extended for parental and caregiving leave (previously limited)

Hospital & Emergency coverage

• Level 1 of the baseline coverage for hospitalization to increase to $90 per day (from $60)
• Level 2 and 3 rates to increase $30 each ($170 for level 2 and $250 for level 3)
• Out of country coverage to be for 40 days exclusive of periods of work, with coverage now at $1M per trip (from $500,000)
• Family Assistance benefits overall maximum to increase to $5,000 (from $2,500)
• Daily allowance for meals and accommodations under family assistance benefits to increase to $200 per day (from $150)

Innovating with digital tools, industry partnerships, new technologies, & preventative care

• Allow nurse practitioners to provide prescriptions for nursing coverage or medical supplies, provided it is in their scope of practice (previously excluded)
• Removal of the physiotherapy coordinator and introduction of a $1500 maximum (new cap)
• New coverage for needles when prescribed at $200
• Spousal definition amendment to remove the requirement that the relationship is publicly known
• Acupuncture coverage at $500 when performed by an accredited acupuncturist (doctor requirement removed)
• $200 annual hearing aid repair allowance (new), battery allowance ($200) and $1500 max every 5 years (from $1000)
• Permanence of coverage for certain medical procedures not covered in all provinces and territories (previously excluded)

Adopting a long term vision of sustainable, efficient, & affordable health care

• Mandatory Generic Substitution/biosimilar substitution with a rigorous exception process (new criteria for exceptions)
• Dispensing fee cap at $8 per medication except for certain special medications (new)
• Maintenance drug frequency filling maximum at 5 times per year when appropriate and when co-pay is less than $100 for a 3-month period (new)
• Compound drugs only covered when one active ingredient would otherwise be covered under the drug benefit (new)
• Catastrophic drug-coverage maximum raised to $3500 (from $3000)
• Members can avoid increased out-of-pocket drug costs or even lower them by filling medications for 3-month periods (when allowed) and choosing a low-cost pharmacy such as a mail order or membership club pharmacy. These options are available to all plan members without a membership or extra fees.

Coverage for diabetic conditions

• Insulin jet injectors at $1000 every 3 years (from $760)
• Coverage for diabetic monitors without use of insulin pump up to $700 per 5 years
• New coverage for continuous glucose monitor supplies (type I diabetics) at $3000
• New coverage for other diabetic testing supplies (type II diabetics) such as flash glucose supplies and testing strips up to $3000

Amendments to Retirement Benefits

• Premium waiver for low-income retirees extended to those who retired after 2015 (previously excluded)
• Retirees with 6 years of service are eligible for retiree benefits regardless of if this service is pensionable or not (can accumulate PSHCP eligible service after retirement/age 71)
• Post-retirement re-employment will no longer negatively impact subsequent retiree coverages

Amendments to Coverage During Leave & Other Definitions

• Coverage now at regular premium rates for the full period of parental leave and any period of caregiving leave
• Definition of common law spouse amended to remove the requirement that one must publicly represent themselves as spouses

For more information about the changes and new contract, click here.

The plan updates are for informational purposes only. PS asks members to please refer to final updates as listed on the plan website when they become available before making a purchase.