Whereas a Memorandum of Understanding (MOU) dated January 13, 2006, between Treasury Board, the National Joint Council (NJC) Bargaining Agents and the National Association of Federal Retirees (NAFR) concerning the 2011 renewal of the Public Service Health Care Plan (referred hereinafter as "PSHCP" or "Plan") sets out the process for future Plan renewal, this Plan Directive sets out the terms of the PSHCP, as approved by Treasury Board of Canada.
Application
This Directive applies to employees and pensioners and is deemed to be part of the collective agreements between the Treasury Board of Canada and bargaining agents that are parties to the NJC.
Effective Date
This Directive is effective on July 1, 2023.
Purpose and Scope of the PSHCP
The purpose of the Public Health Care Plan (PSHCP) is to reimburse Plan participants for all or part of costs they have incurred and paid in full for eligible services and products, as identified in the Plan Directive, 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 Directive, all eligible services and products must be prescribed by a physician, nurse practitioner or dentist who is licensed, or otherwise authorized 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 is within reason in the geographic area where the expense is incurred, subject to limitations which are identified in the Plan Directive.
Claims Appeal Procedure
The grievance procedure set out in section 15 of the NJC By-laws does not apply to this Plan Directive or the PSHCP or any policy relating thereto. A separate and distinct appeal procedure is provided under the PSHCP. Any decision taken by the PSHCP Administration Authority, within the meaning of the PSHCP, in respect of an appeal regarding claims or coverage shall be final and binding. The PSHCP appeal process is outlined in section 5.2.
Management of the Public Service Health Care Plan
PSHCP Governance
PSHCP Governance consists of two (2) governance bodies, the PSHCP Partners Committee and the Federal PSHCP Administration Authority.
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 Plan Directive.
Amendment of the Plan Directive
The Plan Directive may be amended from time to time based on recommendations provided by the Partners Committee that have been approved by the Treasury Board of Canada.
Definitions
In this Plan Directive, unless the context requires otherwise:
Acupuncturist (acupuncteur) - a person licenced or certified as an acupuncturist in the province or territory where they render services or a person with comparable qualifications as determined by the Plan Administrator.
Administrative Services Only Contract (contrat de services administratifs seulement) - the contract between the Government of Canada and the Plan Administrator setting out the services to be provided by the Plan Administrator in respect of the Plan, as amended from time to time.
Audiologist (audiologiste) - a person who is a member or is qualified to be a member of the provincial/territorial college or association, or in the absence of such registry, a person with comparable qualifications as determined by the Plan Administrator.
Biologic Drug (médicament biologique) - a drug made from living organisms or its products and is used in the prevention, diagnosis or treatment of a medical condition and approved by Health Canada.
Biosimilar Drug (médicament biosimilaire) - a drug that has been approved by Health Canada which is highly similar to its reference biologic counterpart drug.
Calendar Year (année civile) - January 1 to December 31.
CAF (FAC) - Canadian Armed Forces.
Children's Benefit (prestation pour enfants) – an ongoing benefit payable pursuant to any of the relevant acts listed in Schedule IV.
Chiropodist (chiropodiste) – a person licensed by the appropriate provincial/territorial licensing authority or in those provinces/territories where there is no licensing authority, members of the Canadian Association of Foot Professionals, or in the absence of such association, a person with comparable qualifications as determined by the Plan Administrator.
Chiropractor (chiropraticien) – a member of the Canadian Chiropractic Association or of a provincial/territorial association affiliated with it, or in the absence of such association, a person with comparable qualifications as determined by the Plan Administrator.
Chronic Disease (maladie chronique) – a condition that exists beyond the usual course of an acute disease or beyond a reasonable time for tissue damage to heal. Any condition that lasts longer than six (6) months may be considered chronic.
Common-Law Partner (conjoint de fait) – a person with whom a member is cohabiting in a conjugal relationship for a period of at least one year.
Community Nursing Station (poste de soins infirmiers communautaire) - an outpatient clinic, centre or facility which offers the services of a nurse who provides health care.
Compendium of Pharmaceuticals and Specialties (CPS) (Compendium des produits et spécialités pharmaceutiques [CPS]) - the reference manual as amended from time to time, containing information about products intended for human use, which is compiled annually and produced by the Canadian Pharmacists Association for the benefit of health professionals.
Coordination of Benefits (CoB) (coordination des prestations [CoP]) – a provision designed to eliminate duplicate payments and to provide the sequence in which coverage will apply when a Plan participant is covered under two or more benefit plans. The Canadian Life and Health Insurance Association (CLHIA) benefit coordination guidelines, as amended from time to time, which are recognized by the majority of insurance companies, have been adopted for the PSHCP or, if unresolved by such guidelines, in accordance with the rules made by the PSHCP Administration.
Co-Payment (co-assurance) – the proportion of eligible expenses not reimbursed by the Plan which remains the responsibility of the Plan member.
Dentist (dentiste) – a person licensed to practice dentistry by the provincial/territorial licensing authority, or in the absence of such authority, a person with comparable qualifications as determined by the Plan Administrator.
Dependant (personne à charge) – a member's spouse or common-law partner, a dependant child of a member or the dependant child of the member's spouse or common-law partner.
Dependant Child (enfant à charge) – a person who is a child of a member or of the member's spouse or common-law partner, including a child for whom the member, the member’s spouse or common-law partner stands in loco parentis, provided such person is:
- under 21 years of age;
- under 25 years of age and attending an accredited school, college or university on a full-time basis; or
- a person over 20 or 24 years of age who was a dependant child as defined above when they became incapable of engaging in self-sustaining employment by reason of mental or physical impairment, and is primarily dependent upon the member for support and maintenance.
Deputy Head (administrateur général) - has the meaning given that expression in the Public Service Employment Act and includes the Commissioner of the RCMP.
Designated Officer (agent désigné) – compensation or pension officer/advisor responsible for receiving and actioning application requests upon verification of eligibility.
Dietitian (diététiste) - a person who is an expert in identifying and treating or preventing disease-related malnutrition conditions and/or conducting medical nutrition therapy including the provision of consultative nutritional services and who is professionally licensed or certified in the province or territory where they render services or a person with comparable qualifications as determined by the Plan Administrator.
Durable Equipment (appareil durable) – an eligible device that does not achieve any of its primary intended health purposes by chemical action or by being metabolized.
Electrologist (électrolyste) – a person who, as determined by the Plan Administrator, qualifies as a certified electrologist.
Employee (employé):
- a person who holds an office, or position, or performs services for which the remuneration is payable out of the Consolidated Revenue Fund of Canada or by an agent of His Majesty in right of Canada;
- a person designated by the Treasury Board of Canada as being eligible to join the Plan as listed in Schedule III of this Plan Document, as amended from time to time by the Treasury Board of Canada;
- a person who is an employee of a participating employer as listed in Schedule I of this Plan Document, as amended from time to time by the Treasury Board of Canada; or
- a person who is a member of a civilian component of the forces of a state that is a party to the North Atlantic Treaty Status of Forces Agreement, 1949 who is serving in Canada.
Employer (employeur) – the Treasury Board of Canada.
Explanation of Benefits (EoB) (relevé des prestations) – also referred to as the “Claim Statement”, the Plan Administrator’s written explanation which provides details about a health care insurance claim that has been processed. The EoB details the services and/or products that were submitted, and it explains what portion was paid by the Plan and what portion of the payment, if any, is the member’s responsibility. In the case of a point-of-sale transaction at the pharmacy, the pharmacy receipt is considered the EoB.
Family Member (membre de la famille) – a member or a covered dependant.
Federal PSHCP Administration Authority or Administration Authority (Administration du RSSFP ou Administration) - the corporation without share capital whose mandate is to oversee the administration of the PSHCP. The PSHCP Administration Authority ensures that the Plan Administrator delivers benefits efficiently and effectively to PSHCP members in accordance with the Plan provisions. The PSHCP Administration Authority is accountable to the Partners Committee.
Fee Guide (guide des tarifs) – for services provided by dentists, refers to charges established by the provincial/territorial dental association in the province/territory in which the expense is incurred or, in the absence of such association, comparable charges considered reasonable and customary, as determined by the Plan Administrator.
Generic Drug (médicament générique) - a prescription drug that has the same active-ingredient formula, amount and in a similar dosage as a brand-name drug.
Hospital (hôpital) – a legally licensed hospital which provides facilities for diagnosis, major surgery and the care and treatment of a person suffering from disease or injury on an in-patient basis, with 24-hour services by nurses and physicians. A hospital also is a legally licensed hospital providing specialized treatment for mental illness, drug and alcohol addiction, cancer, arthritis and convalescing or chronically ill persons. This does not include nursing homes, homes for the aged, rest homes or other places providing similar care.
Hospitalized/Hospitalization (hospitalisé/hospitalisation) - admitted to a hospital for in-patient treatment.
Lactation Consultant (consultant en lactation) - a person who specializes in breastfeeding/chestfeeding and trained to recognize and prevent or solve breastfeeding/chestfeeding difficulties with a recognized certification or a person with comparable qualifications as determined by the Plan Administrator.
Lifetime Maximum (maximum remboursable à vie) - the maximum dollar amount the PSHCP Plan agrees to pay on behalf of a participant for an identified covered service or product during the participant’s lifetime.
Lowest Cost Alternative (médicament de substitution le moins coûteux) - the lowest priced drug that has been proven to provide effective treatment for a specific disease.
Maintenance Drug (médicament d’entretien) - prescriptions medications commonly used to treat conditions that are considered chronic or long-term. These conditions usually require regular use of medications.
Massage Therapist (massothérapeute) – a person licensed by the appropriate provincial/territorial licensing body or, in the absence of a provincial/territorial licensing body, a person with comparable qualifications as determined by the Plan Administrator.
Member (participant):
- an employee or a pensioner who has applied for and has been granted coverage under the PSHCP by a designated officer; or
- a member of the CAF or the RCMP who has applied for and has been granted coverage for their dependants under the PSHCP;
- an individual who is a member of the VAC client group as defined in Schedule III who has applied for and has been granted coverage under the PSHCP.
Member of the Canadian Armed Forces (CAF) (membre des Forces armées canadiennes [FAC]) – a person who is:
- a member of the regular armed force of the CAF;
- a member of the CAF, other than a member of the regular force, and as an individual or as a member of a class, has been designated by the Treasury Board of Canada as a member of the forces for the purposes of this Plan Document; or
- a member of the forces of a state that is a party to the North Atlantic Treaty Status of Forces Agreement, 1949 who is serving in Canada.
Minister (Ministre) – the President of the Treasury Board of Canada.
Month (mois) – the period of time from a date in one (1) calendar month to the same date in the following calendar month.
National Association of Federal Retirees (Association nationale des retraités fédéraux) – an association of federal retirees representing all pensioner members of the Plan at the Partners Committee.
National Joint Council (NJC) (Conseil national mixte [CNM]) - National Joint Council, a consultative body established pursuant to Treasury Board Minute T.272382B of March 1945, providing regular consultation between the government and employee organizations certified as bargaining agents on common employee issues.
Naturopath (naturopathe) – a member of the Canadian Naturopathic Association or any provincial/territorial association affiliated with it, or in the absence of such association, a person with comparable qualifications as determined by the Plan Administrator.
Nurse (infirmier) – a registered nurse, registered nursing assistant, registered practical nurse, licensed practical nurse, or certified nursing assistant who is listed on the appropriate provincial/territorial registry and, in the absence of such registry, a nurse with comparable qualifications as determined by the Plan Administrator.
Nurse Practitioner (infirmier practicien) - a registered nurse who has additional education and nursing experience, who is listed on the appropriate provincial/territorial registry and, in the absence of such registry, a nurse with comparable qualifications as determined by the Plan Administrator.
Occupational Therapist (ergothérapeute) - a person who is a member or is qualified to be a member of the relevant provincial/territorial college or association, or in the absence of such registry, a person with comparable qualifications as determined by the Plan Administrator.
Ophthalmologist (ophtalmologiste) – a person licensed to practice ophthalmology and registered with the appropriate provincial/territorial association or registry, or in the absence of such association, a person with comparable qualifications as determined by the Plan Administrator.
Optometrist (optométriste) – a member of the Canadian Association of Optometrists or of a provincial/territorial association associated with it, or in the absence of such association, a person with comparable qualifications as determined by the Plan Administrator.
Osteopath (ostéopathe) – a person licensed to practice osteopathic medicine, by the appropriate provincial/territorial body, or in the absence of a provincial/territorial licensing body, or a person with comparable qualifications as determined by the Plan Administrator.
Participant (personne protégée) - a person covered under the PSHCP.
Participating Employer (employeur participant) – a Board, commission, corporation or other portion of the federal public administration, which is specified in Schedule I of this Document, as amended from time to time by the Treasury Board of Canada.
Patient Support Program (programme de soutien aux patients) - a program that may be available that aids a Plan participant in obtaining coverage for a drug, service, or supply listed on the Plan Administrator’s list of drugs, services, and supplies for which prior authorization is or is not necessary.
Partners Committee (Comité des partenaires) - the committee established by the President of the Treasury Board of Canada, comprised of representatives of the Employer, that portion of the National Joint Council of the Public Service that represents the employees, and an individual appointed by the National Joint Council who represents the pensioners.
Pension (pension) – a recognized ongoing pension benefit, a survivor's benefit or a children’s benefit pursuant to any Acts listed in Schedule IV of this Plan Document, as amended from time to time by the Treasury Board of Canada.
Pensioner (retraité) – a person who is in receipt of a recognized ongoing benefit, a survivor's benefit or a children’s benefit pursuant to any Acts listed in Schedule IV of this Plan Document, as amended from time to time by the Treasury Board of Canada.
Pharmacist (pharmacien) – a person who is licensed to practice pharmacy and whose name is listed on the pharmacists’ registry of the licensing body for the jurisdiction in which such person is practicing.
Physician (médecin) – a Doctor of Medicine (M.D.) legally licensed to practice medicine.
Physiotherapist (physiothérapeute) – a member of the Canadian Physiotherapy Association or of a provincial/territorial association affiliated with it, or in the absence of such association, a person with comparable qualifications as determined by the Plan Administrator.
Plan (Régime) – the Public Service Health Care Plan.
Plan Administrator (Administrateur du Régime) - for the purposes of this Plan Directive, the organization contracted to adjudicate and pay claims under an Administrative Services Only Contract with the Government of Canada in accordance with the Plan Directive and/or direction from the PSHCP Administration Authority.
Podiatrist (podiatre) – a person licensed by the appropriate provincial/territorial licensing authority or in those provinces/territories where there is no licensing authority, members of the Canadian Association of Foot Professionals, or in the absence of such association, a person with comparable qualifications as determined by the Plan Administrator.
Psychologist (psychologue) – a permanently certified psychologist who is listed on the appropriate provincial/territorial registry in the province/territory where the service is rendered, or in the absence of such registry, a person with comparable qualifications as determined by the Plan Administrator.
Psychotherapist/Registered Counsellor (psychothérapeute/ conseiller autorisé) - a person licensed by the appropriate provincial/territorial licensing authority, or in the absence of such association, a person with comparable qualifications as determined by the Plan Administrator who specializes in the use of counselling or an in-depth form of talk therapy.
PSHCP (RSSFP) – Public Service Health Care Plan.
Reasonable and Customary (R&C) Charges (frais habituels et raisonnables [H&R]) – that amount which is usually charged to a person without coverage, and which does not exceed the general level of charges for the specific service or product in the geographic location where the expense is incurred, as determined by the Plan Administrator. Published Fee Guides of national, provincial or territorial associations of practitioners will be consulted for this purpose where applicable.
Reasonable Treatment (traitement raisonnable) - a treatment that is accepted by the Canadian medical profession, proven to be effective; and, of a form, intensity, frequency, and/or duration essential to the diagnosis or management of the disease or injury.
Remuneration (rémunération) – includes salary, wages, pay and allowances, pension, annual allowance, sessional allowance and annuity.
RCMP (GRC) – Royal Canadian Mounted Police.
Social Worker (travailleur/travailleuse social) - a person who is listed on the appropriate provincial/territorial registry in the province/territory where the service is rendered, or in the absence of such registry, a person with comparable qualifications as determined by the Plan Administrator.
Speech Language Pathologist (orthophoniste) - a person who is a member or is qualified to be a member of the Canadian Speech and Hearing Association or any provincial/territorial association affiliated with it, or in the absence of such registry, a person with comparable qualifications as determined by the Plan Administrator.
Survivor Benefit (prestation de survivant) - an ongoing pension benefit payable pursuant to any of the relevant acts listed in Schedule IV.