Public Service Health Care Plan FAQ’S
Budget 2014 announced the Government of Canada’s intention to move to a 50:50 (employer to retired member) cost sharing model and changes to retired member eligibility.
- What is my Public Service Health Care Plan (PSHCP)?
- What is covered under the PSHCP?
- Does PSHCP pay 100% of my costs?
- How do I know if I am a member?
- How much do I pay for my Health Care Plan?
- Who can I cover as a dependant?
- What happens to my PSHCP coverage when I go on Leave Without Pay?
- Am I covered if I need medical or hospital services while travelling outside Canada?
- Can I change my coverage levels at any time?
- How do I make a claim for benefits under the PSHCP?
- Am I covered under the PSHCP if I am posted outside of Canada by my employer?
- What happens to my coverage when I retire or otherwise leave the Public Service?
- If I join the PSHCP when I retire, will I be covered under the same terms as when I was an employee?
What is changing?
Effective April 1, 2015, retired members’ cost sharing will be phased in over a four-year period as follows in the table below. Annual adjustments will be made to all contribution rates during the phase-in period and thereafter to reflect actual plan experience.
Members who were retired or will retire before March 31, 2015, will not be affected by the cost-sharing change if a completed PSHCP Relief Provision application is received and approved due to your income being below the Guaranteed Income Supplement thresholds under the Old Age Security Act.
|Effective Date||Cost Sharing for Retired Members|
|Retired Member||Government of Canada|
|April 1, 2015||31.25%||68.75%|
|April 1, 2016||37.5%||62.5%|
|April 1, 2017||43.75%||56.25%|
|April 1, 2018||50%||50%|
Effective January 1, 2015, the annual deductible will be eliminated. Plan members will no longer have to pay the first $60 for single coverage or $100 for family coverage per calendar year.
Effective October 1, 2014, the following benefit enhancements will be introduced for costs incurred on or after the effective date for all members of the Public Service Health Care Plan and reimbursed at 80%:
- Expanded vision care benefit to include reimbursement for elective laser eye surgery with a lifetime maximum benefit of $1,000, reimbursed at 80%;
- Coverage for repairs, replacement parts and servicing of aerotherapeutics devices with an annual maximum benefit of $300, reimbursed at 80% (physician’s confirmation of level of sleep apnea is required); and,
- An increase to the annual maximum benefit for psychological services from $1,000 to $2,000, reimbursed at 80%.
Effective April 1, 2015, new retirees will require a total of six years or more of pensionable service to be eligible as a retired member under the Public Service Health Care Plan. However, some exemptions will apply, such as for disabled retired members, survivors, the Veterans Affairs Canada client group and those affected by Workforce Adjustment.
Plan members are encouraged to consult the Public Service Pension and Benefits Web Portal for information on updates and changes to the Plan.
Why are these changes being made?
The Public Service Health Care Plan provides voluntary, supplementary health care benefits to public service employees, employees of designated separate employers, MPs and senators, retired public service employees, and eligible dependents as well as dependents of the Canadian Forces and the Royal Canadian Mounted Police. In total, the Public Service Health Care Plan has over 630,000 members, of which almost 300,000 are retired members, and covers over 1.4 million Canadians. It is the largest employer-sponsored health care plan in Canada.
These changes are consistent with the Government’s commitment to ensuring compensation is reasonable and affordable, as well as aligned with similar plans offered by other public sector and private sector employers. To address this, Budget 2014 announced the Government of Canada’s intention to move to a 50:50 (employer to retired member) cost sharing model and to make changes to retired member eligibility.
These changes are the result of a joint recommendation by the Public Service Health Care Plan Partners Committee, the collaborative forum for the resolution of issues pertaining to the Plan, comprised of employer representatives, bargaining agents, and pensioner representatives.
What is my Public Service Health Care Plan (PSHCP)?
The Public Service Health Care Plan (PSHCP) is an optional health care plan for federal Public Service employees and their eligible dependants.
It is designed to supplement your provincial health insurance plan. In other words, the Plan will reimburse you for all or part of your costs for eligible medical services and products once you have taken advantage of the benefits provided under your provincial/territorial health insurance plan or other third party source of health care assistance to which you are legally entitled. Complete details on the Public Service Health Care Plan are set out in the Public Service Health Care Plan Directive.
You can also find information on the Public Service Health Care Plan page of the TBS web site or directly in the plan member booklet "Public Service Health Care Plan - Benefits Coverage and Plan Provisions" available on the Sun Life site.
In addition, the Plan Administrator, Sun Life, has a Plan Member Services Web site to provide members with secure access to claims and benefit eligibility information, personalized claim forms, direct deposit information and access to update positive enrolment information. An Access-ID and password are needed. You can get these by registering online at Sun Life or by calling the Sun Life Assurance Company of Canada at:
- 1-888-757-7427 (toll-free in North America)
- (613) 247-5100 in the National Capital Region
PSHCP members may also visit the Public Service Health Care Plan Administration Authority web site.
What is covered under the PSHCP?
The benefits covered under the Health Care Plan fall into 2 broad categories: Extended Health Care Benefits and Hospital Benefits.
Extended Health Care Benefits – the PSHCP reimburses plan members for reasonable and customary charges for specific medical services and products. Examples of these are prescription drugs, private nursing services, eyeglasses and contact lenses, some physiotherapist and massage therapist services, orthotics and ambulance services.
Hospital Benefits – members and their dependants are covered for hospital charges in excess of standard ward charges up to specified limits. There are 3 levels of coverage available to members:
- Level I provides for a maximum payment of $60 per day;
- Level II provides for a maximum payment of $140 per day; and
- Level III provides for a maximum payment of $220 per day.
If you join the Plan, you are automatically covered for Level I benefits unless you elect for Level II or III.
A complete description of what is covered under the Plan can be found in the Public Service Health Care Plan Directive.
You can find related information on the TBS Public Service Health Care Plan page on the TBS web site, directly in the plan member booklet "Public Service Health Care Plan - Benefits Coverage and Plan Provisions" available on the Sun Life site and on the Public Service Pension and Benefits Web Portal.
Does PSHCP pay 100% of my costs?
For Extended Health Care Benefits, the plan generally pays you 80 % of eligible expense(s). For some services or products, however, there are annual maximum eligible expenses, i.e., psychologist’s services can be reimbursed to a maximum of $2000 per year. Note: some services do require a physician's referral.
For Hospital Benefits, the plan includes three levels of hospital benefits that provide reimbursement up to a specific dollar amount in excess of standard ward charges. Level I pays a maximum of $60 per day towards the cost of your accommodation, Level II a maximum of $140 per day and Level III a maximum of $220 per day. Level I coverage is provided automatically to all members.
How do I know if I am a member?
The PSHCP is a voluntary plan for employees who are appointed for more than 6 months. It is available to full time and part time eligible employees. Applications must be completed and submitted either electronically using the secure online Public Service Health Care Plan Web Application on the Compensation Web Applications (CWA) or, by paperto your departmental Compensation. Members can also apply to cover eligible dependants.
Once you are registered you must complete your positive enrolment with the administrator, Sun Life Financial, to provide information about yourself, your spouse/common-law partner and each eligible child.
Those already registered as a user on the Sun Life Plan Member Services Web site for the PSHCP can enroll online using their access ID and password.
Those not yet registered as a user on the Sun Life Plan Member Services Web site for the PSHCP can register as a user now, and then enroll online.
On joining, if elected to receive one, plan members receive a benefit card showing their certificate number and the level of coverage they have chosen. A plan member can also print a benefit card directly from the Sun Life Plan Member Services Web site.
How much do I pay for my Health Care Plan?
Once you have applied to be a Plan member, the Government as your employer pays the full cost of your Extended Health Care Benefit, i.e., Hospital Level I coverage.
Employees who choose Level II or Level III Hospital Benefits will pay a monthly contribution depending on their category of coverage (single versus family).
Contributions are taken from employees’ pay one month in advance of coverage. I.e. contributions taken in a given month pays for coverage in the following month.
Members of the Executive Category receive 100% employer paid Family Level III Hospital coverage. This is a taxable benefit.
Please also refer to the question What happens to my PSHCP coverage when I go on Leave Without Pay?
Who can I cover as a dependant?
As a plan member, you can apply for coverage for the person to whom you are legally married. Alternatively, you may apply for coverage for the person with whom you have lived for a continuous period of at least one year, whom you have publicly represented as your spouse and with whom you continue to live as if that person were your spouse.
You may also cover any of your or your spouse’s eligible dependant children. To be eligible as a dependant child, the person must be unmarried and either under the age of 21 or be under the age of 25 and a full time student. A child who is dependent upon you for support because he or she is incapable of engaging in sustainable employment by reason of mental or physical impairment may also be covered under certain circumstances, as set out in the Public Service Health Care Plan Directive.
Important: There are time limits for applying for coverage of new dependants. Refer to the Public Service Health Care Plan Directive for details.
What happens to my PSHCP coverage when I go on Leave Without Pay?
Generally speaking, you can continue to be covered under the PSHCP when on leave without pay. However, depending upon the length of your leave and the type of leave, you may be required to pay the full cost of your coverage (i.e. the employer and employee monthly contributions combined).
Before proceeding on leave, you should consult your departmental Compensation for information regarding PSHCP coverage continuation and its financial impacts. If you wish to cancel your PSHCP coverage while on leave, you must provide a written request to your departmental Compensation to opt out of the Plan. If not, you will be deemed to have opted to continue coverage and pay all necessary contributions upon your return to work or discharge.
If you choose to continue your coverage while on leave, you can make arrangements to pay contributions in advance. To do so you must complete and return a Contribution Remittance for Period of Leave Without Pay form obtained from Compensation.
Failure to pay the required contributions will result in your coverage being terminated at the end of the month following the month for which your last contribution was made. You may re-instate your coverage when you return to duty but you cannot do so retroactively. Note: Re-instatement may be subject to a waiting period of up to four months.
Refer to the Public Service Health Care Plan Directive for details.
Am I covered if I need medical or hospital services while travelling outside Canada?
The PSHCP covers members and their dependants for up to $500,000 (Canadian) in eligible medical expenses incurred as a result of an emergency while traveling on vacation or business.
Eligible expenses are described in the Public Service Health Care Plan Directive and the Benefits Coverage and Provisions Booklet available on the Sun Life site. They include charges for hospital accommodation and the services of a physician. They can also include reasonable costs for medical evacuation, family assistance for travel, meals and childcare.
Eligible expenses mean charges in excess of the amount payable by a provincial or territorial health insurance plan for emergency treatment of injury or disease which occurs within 40 days from the date of departure from your province or territory of residence.
The 40 day time limit does not apply in the case of employees who are travelling on official government business. They are covered for the entire period of official travel status. However, the $500,000 benefit coverage limit still applies.
If you are travelling outside Canada, be sure to take with you the Public Service Emergency Travel Assistance telephone numbers. These numbers are listed in the Public Service Health Care Plan Directive and found on the back of your PSHCP benefit card.
Can I change my coverage levels at any time?
You can apply to cover dependants or cancel dependants’ coverage or to amend your level of Hospital Provision coverage at any time except while you are on leave without pay. The effective date of the amended coverage will depend upon the type of change you are making and the timeframe within which you make it.
Refer to the Public Service Health Care Plan Directive for details
How do I make a claim for benefits under the PSHCP?
Claims are made either electronically by presenting your PSHCP benefit card at a recognized pharmacy or by completing the PSHCP claim form, attaching original bills and receipts and forwarding these to the PSHCP administrator, Sun Life Assurance Company of Canada. The Public Service Health Care Plan Claim Form is available online.
Questions about PSHCP claims should be directed to Sun Life Assurance Company of Canada at:
- 1-888-757-7427 (toll-free in North America)
- (613) 247-5100 in the National Capital Region
Alternatively, members can find information on the status of their claims by logging onto the Sun Life Plan Member Services Web site. An Access-ID and password are needed. You can get these by registering online at Sun Life or by calling the numbers listed above.
Am I covered under PSHCP if I am posted outside of Canada by my employer?
Yes, though your coverage will be different. You will be eligible for Comprehensive coverage which is intended for plan members who are posted outside Canada and who are not covered under a provincial or territorial health insurance plan or a non-government hospital insurance plan.
Comprehensive coverage includes Basic Health Care, the Extended Health Provision, the Hospital provision and the Hospital Expense (Outside Canada) provision. A full description of these provisions can be found in the Public Service Health Care Plan Directive.
The Basic Health Care provision provides 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 Hospital Expense (Outside Canada) 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.
Contribution rates for Comprehensive coverage can be found in the Public Service Health Care Plan Directive.
What happens to my coverage when I retire or otherwise leave the Public Service?
If you retire and begin receiving an immediate on-going pension under the Public Service Pension Plan, you may continue your PSHCP membership without interruption.
If you do not receive an immediate pension, your coverage terminates when your employment terminates. However, if a PSHCP contribution has been taken in the month in which your employment terminates, coverage will continue until the end of the following month.
If I join the PSHCP when I retire, will I be covered under the same terms as when I was an employee?
As a retired member, your contribution rates will be different from those you paid as an employee. The rates for pensioners living in Canada are listed in the monthly contribution rates in Schedule V of the Public Service Health Care Plan Directive.
Pensioners living outside Canada will pay higher rates and may not be covered for the same Hospital expenses as pensioners living inside Canada.
Refer to the Public Service Health Care Plan Directive for full information on rates and coverage.
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