FSD 39 - Health care expenses
Introduction
This directive provides financial assistance to employees who incur health care expenses outside Canada which exceed those permissible under the Public Service Health Care Plan (PSHCP) and the Public Service Dental Care Plan (PSDCP), subject to certain conditions as specified in the directive.
Directive 39
39.01 For purposes of this directive, dependant means each dependant or dependent student as defined in FSD 2.01(k) or 2.01(l), respectively, who
(a) is residing with the employee at the post, or
(b) is in full-time attendance at an educational institution outside of Canada.
Instruction
It is essential that employees maintain comprehensive family coverage under the PSHCP for dependent students, normally resident in Canada, who visit the post for more than 40 days at one time.
39.02 Subject to the provisions of Section 39.05, where expenses have been incurred for health care, drugs or dental treatment in respect of an employee and/or a dependant which are in excess of eligible expenses under the Public Service Health Care Plan or the Public Service Dental Care Plan, the deputy head may authorize reimbursement to the employee of the amount in excess, provided:
(a) the employee pays the deductible share under the Public Service Health Care Plan or the Public Service Dental Care Plan or the share which would have been applicable for insurance under these plans; and
(b) the employee pays any co-insurance applicable under the Public Service Health Care Plan or the Public Service Dental Care Plan or the amount of co-insurance which would have been applicable for insurance under these plans; and
(c) the expenses involved have been incurred pursuant to consultation with a medical practitioner or dentist acceptable to Health Canada;
(d) the employee submits a claim under the Public Service Health Care Plan or the Public Service Dental Care Plan within the time constraints of the plan (usually 12 months) except that;
(e) where a claim is denied under the Public Service Dental Care Plan because it is for treatment which was previously claimed, and the required time has not elapsed before another claim may be made, the deputy head may authorize reimbursement in such amount as may be recommended by the Administrator of the Plan to reflect the amount which would otherwise have been payable under the PSDCP as an initial claim, plus any excess dental costs identified by the Administrator of the Plan and payable under this directive. This provision is designed to provide for those necessary additional costs resulting from initial incompetent/inadequate treatment, where the employee is no longer at the location where the original treatment took place or, in the opinion of Mission administration, cannot obtain redress from the original practitioner.
(f) where the treating physician certifies that a psychiatrist is not available at the mission and therefore recommends treatment by a psychologist, the deputy head may authorize reimbursement of psychologist fees which may be in excess of the maximum amount reimbursable under the PSHCP.
Instruction
Where an advance has been authorized under FSD 42 - Medical and/or dental expense advance, and a claim is rejected under the plan because of lateness, the employee shall be responsible for full repayment of the advance, which shall be subject to recovery pursuant to the relevant provisions of the Financial Administration Act.
39.03 The amount payable under Section 39.02 shall not exceed the amount over and above that which the employee is eligible to receive as a participant in any other plan of health insurance.
Instruction
Section 39.03 recognizes those situations where an employee incurs health care expenses outside Canada while still covered by a provincial health insurance plan following departure from Canada.
39.04 The health care referred to in this directive may include para-medical care and the services of medical and dental specialists, provided such services have been recommended pursuant to consultation with a medical practitioner or dentist acceptable to Health Canada.
Instructions
1. Each Post shall compile a roster of qualified local medical practitioners and dentists whom personnel at the post may consult. The roster should include medical internists, obstetricians, pediatricians and general practitioners and dental general practitioners and specialists.
2. Where costs for medical and hospital care, drugs and/or dental treatment are excessive, and the treatment can be deferred, an employee should explore the possibility of obtaining treatment at an alternative location. In such cases the employee should contact the deputy head who shall determine the cost effectiveness of obtaining treatment at an alternative location, including the cost of health care travel and related expenses under FSD 41 - Health care travel; the deputy head may thereafter authorize treatment at a location other than the employee's post.
3. Where a Health Canada physician certifies, and where the appropriate foreign service inter-departmental coordinating committee recommends that the treatment that occurred is consistent with the treatment which would have occurred within a hospital, the deputy head may authorize reimbursement of a claim that has been denied by the Public Service Health Care Plan.
4. Employees shall be required to submit receipted accounts showing the differences between their actual expenses and those admissible under the PSHCP or the PSDCP, or their plan of health or hospitalization insurance.
5. In claiming for health care expenses which are in excess of eligible expenses under the PSHCP, the employee should include the detailed statement provided by the Administrator of the Plan. It should be noted that a claim may not be made for expenses which are not admissible under the PSHCP or which exceed specific dollar limits under the PSHCP as these are expenses which would be incurred by employees in Canada.
6. In claiming for excess hospital costs, an adjustment will be made where an employee has less than maximum coverage. For example, an employee incurs excess costs of $200.00 per day for semi-private hospital coverage and has Level I coverage which provides a benefit of $60.00 per day rather than Level III coverage which provides a benefit of $220.00 per day. The claim would be reduced by the difference between Level III and Level I coverage, that is, $160.00, and the employee would receive an adjusted amount of $200.00 minus $160.00, or $40.00.
7. Employees may claim for dental care expenses to the extent which would place them in the same position as employees in Ontario. Where eligible expenses under the Public Service Dental Care Plan which are incurred outside Canada are higher than in Ontario, employees may submit a claim for that portion of the cost which they are required to pay outside Canada and which would not be incurred in Ontario. For example, and assuming the deductible has been satisfied and reimbursement under the dental plan is at 50%, if in Ontario the eligible expense for a service is $400 (with the employee paying $200) and outside Canada the eligible expense is $600 for the same service (with the employee paying $300), then the cost to the employee is $100 more than it would be in Ontario. The employee could then claim $100 under this directive. This would place the employee outside Canada in the same position as the employee in Ontario.
8. Except as provided for under the Public Service Health Care Plan, dental care expenses are only eligible for reimbursement under this directive provided the employee, and eligible dependants, were covered, or were eligible to be covered, under the Public Service Dental Care Plan.
9. To assist employees in claiming dental expenses under this directive, the Administrator of the Plan will provide employees outside Canada who claim for dental expenses with the required information on excess dental costs as part of their claims procedure. A copy of the Explanation of Benefits from the Administrator of the Plan identifying the excess dental expenses should be attached to the claim for reimbursement which employees should submit to their departmental headquarters in the same way they would submit a claim for reimbursement of health care expenses under this directive.
10. Section 39.02(e) is designed for those situations where a claim for dental care has been refused by the Public Service Dental Care Plan because the employee is claiming for a specific procedure which was previously paid for under the Plan, under certain circumstances, and the required time has not elapsed before another claim may be made. When, in the opinion of the employee, the duplicate procedure was necessary because of incompetent/inadequate workmanship at a mission outside Canada, the employee should appeal the decision, and request referral to the Board of Management, on the basis of initial shoddy workmanship. While payment cannot be authorized under the Public Service Dental Care Plan, this will enable the Administrator of the Plan to investigate and determine whether a recommendation for payment is justified under this directive.
11. Where a claim for oral surgery has not been paid in full by the Public Service Dental Care Plan, a claim should be submitted to the Public Service Health Care Plan along with copies of the original claim made to the dental plan and the Explanation of Benefits from the Administrator of the Plan. If, following this settlement, there is still an unpaid balance, the employee should submit a claim under this directive, along with copies of the Explanation of Benefits from the Administrators of the Plans.
39.05 Where health care expenses are incurred on behalf of a dependant because of:
(a) an illness due to conditions at a location where the employee and/or a dependant is or has been residing and which is of a type, the incidence of which is greater than in Canada, or
(b) an injury resulting from an event at a location where an employee and/or dependant is or has been residing, and which would not normally occur in Canada, or which gives rise to circumstances not normally experienced in Canada,
the deputy head shall, in determining the amount of reimbursement under Section 39.02, include for payment:
(c) the deductible share attributable to the difference between single and family coverage under the Public Service Health Care Plan or the Public Service Dental Care Plan as applicable; and
(d) the actual amount of co-insurance for which the employee was responsible under the Public Service Health Care Plan or the Public Service Dental Care Plan.
Instruction
Section 39.05 does not apply to employees as they are covered by the Government Employees Compensation Act.
39.06 In reviewing claims for payment pursuant to Section 39.05, the deputy head shall seek and take into consideration the advice of Health Canada in order to confirm that the illness or injury is attributable to conditions at post.
39.07 Where an employee's medical, hospital or dental care insurance under the Public Service Health Care Plan is exhausted by expenses incurred as a result of an illness or injury described in Section 39.05, the deputy head shall authorize payment of the amounts that would have been paid under such plans until such time as the employee's normal coverage is re-established.