PSHCP Bulletin 44

In this issue:

• Transition to the new PSHCP Administrator
• Delisted providers: Don’t pay out of pocket!
• Miscellaneous Expense Benefit: Durable equipment
• We want to hear from you – Member satisfaction survey
• The PSHCP Appeals Process

This Bulletin was published before the transition to the new Plan Administrator, Canada Life. If you have any questions, contact the PSHCP Member Contact Centre at 1-855-415-4414 (toll-free anywhere in North America) or 1-431-489-4064 (call collect if you are outside North America).

Transition to the new PSHCP Administrator

As announced in the previous Bulletin, following a competitive procurement process, the Government of Canada awarded the next contract to administer the Public Service Health Care Plan (PSHCP) to the Canada Life Assurance Company (Canada Life). Canada Life will begin processing claims on July 1, 2023.

For a smooth transition

You can help ensure a seamless transition with no interruption to your coverage by keeping your contact and positive enrolment information up to date with Sun Life. Your information will be securely transferred to Canada Life this fall.

If you already have an online account, sign in to the PSHCP Member Services site at www.sunlife.ca/pshcp, and select Positive enrolment. Review all of your personal information and correct any information that is outdated. To correct any errors that you cannot address through the positive enrolment process, contact your compensation or pension office.

If you do not have an online account, you can create one by selecting Register on the home page.

If you prefer to complete positive enrolment on paper, call the Sun Life Call Centre at 1-888- 757- 7427 (toll free from anywhere in North America) or, in the National Capital Region, at 613- 247-5100, Monday to Friday, 6:30 a.m. to 8:00 p.m. EST. Sun Life will mail the Positive Enrolment Form and instructions to you.

WHAT’S NEXT

• Canada Life will contact you to complete positive enrolment on the Canada Life system.
• Although you won’t be able to submit a claim to Canada Life until July 1, 2023, it is important that you keep your personal information up to date with both Sun Life and Canada Life until the transition is complete.

Remember, until June 30, 2023, you must submit your claims to Sun Life. From July 1, 2023, onward, you must submit your claims to Canada Life.

Delisted providers: Don’t pay out of pocket!

The PSHCP Administrator can delist individual medical service providers as well as clinics, facilities and pharmacies from the plan. If business irregularities are confirmed, the expenses plan members incur for products or services rendered from a delisted provider will not be payable by the PSHCP.

Before you visit a provider, check the online list to ensure the provider has not been delisted. You can find this list by:

1. Signing into the PSHCP Member Services site (www.sunlife.ca/pshcp)
2. Navigating to Benefits » Benefits centre
3. Selecting Take me to » Delisted providers list.

Miscellaneous Expense Benefit: Durable equipment

The purchase or rental of some medically necessary durable equipment is eligible for reimbursement under the PSHCP Miscellaneous Expense Benefit. Eligible equipment is covered at 80% of the reasonable and customary amount of the purchase or rental cost.

To be covered under the PSHCP, equipment must be:

• prescribed by a physician (unless otherwise specified)
• for use in the patient’s private residence
• approved by the PSHCP Administrator for cost effectiveness and clinical value
• designated as medically necessary; and
• manufactured specifically for medical use.

Before purchasing any durable equipment, contact Sun Life to confirm that the item is eligible under the PSHCP. When you submit a claim for durable equipment, include the:

• Date of purchase
• Claimant’s name and address
• Item description
• Quantity
• Cost
• Doctor’s name (unless a prescription is submitted with the receipt)
• Proof of provincial plan coverage (when applicable)
• Facility’s name and address

Your receipt must be personalized and itemized and must indicate that the purchase has been paid in full. Cash register slips are not accepted and claims for some durable equipment items may require additional documentation.

For more information on the Miscellaneous Expense Benefit, contact the PSHCP Call Centre. You can also sign into the Plan Member Services site and click on Chat live now to connect with a Client Care Representative in real-time

We want to hear from you – Member satisfaction survey

Next month, Sun Life will be sending out a Member Satisfaction survey to randomly selected PSHCP members. The survey will assess the performance of Sun Life and its subcontractor, Allianz, in the administration of the PSHCP.

Survey responses and comments will be confidential – individuals will not be identified in any way. Participation in this survey is greatly appreciated as it helps improve the administration of the PSHCP.

Should you have any concerns or require additional information about this survey, contact the PSHCP Call Centre or send an email to can_ottawaservice@sunlife.com.

The PSHCP Appeals Process

PSHCP members who disagree with decisions regarding a claim, benefit entitlement or coverage (e.g., level of coverage, waiting period, refund of contributions) can have their files reviewed. However, before submitting an appeal, try to resolve the issue with the plan Administrator if your appeal is claim-related. Contact your compensation or pension office if your appeal is coverage-related.

How to submit an appeal

You must submit your appeal by mail to the PSHCP Administration Authority at the following address:

PSHCP Administration Authority
P.O. Box 2245, Station D
Ottawa, ON K1P 5W4

Your letter must include your name, current address and certificate number. You, as the member, must sign the document. If you and your spouse or common-law partner are both covered under the PSHCP, and the appeal pertains to both files, both of your signatures are required. Appeals may also be submitted by someone authorized to act on your behalf.

If your appeal relates to a claim or benefit entitlement, it must be submitted to the PSHCP Administration Authority within twelve months of the date of the Claim Statement. Before you submit your appeal, review the relevant section of the PSHCP Directive to confirm that the service or product is covered by the plan. Provide all the relevant facts in your letter, including the reasons for disputing the PSHCP Administrator’s decision and supporting documentation such as:

• Prescriptions
• A description of the service or product for which the claim was submitted, and dates of purchase or service
• Medical questionnaires submitted to the PSHCP Administrator
• A copy of the claim, related receipts and Claim Statement issued by the PSHCP Administrator
• Any relevant correspondence, including dated records of related phone calls or e-mails

If your appeal relates to a coverage issue, describe the circumstances leading to your appeal as well as your justification for the requested adjustment. You should provide supporting documentation such as:

• Copies of application forms submitted to your compensation or pension office
• Forms submitted through the Compensation Web Applications
• Records (with dates) of related phone calls, e-mails, or correspondence to and from your compensation or pension office

The appeals process is the final level of review under the PSHCP. For more information, visit www.pshcp.ca/appeals.

The PSHCP Bulletin is produced by the Federal Public Service Health Care Plan Administration Authority to provide benefit and administrative information about your health care plan. If you have any questions about the content of this bulletin, please contact Sun Life at 1-888-757-7427 toll-free from anywhere in North America or 613-247-5100 in the National Capital Region. If you would like to change your mailing address for future bulletins, you may do so online at www.sunlife.ca/pshcp.