1. When will the new contract start?
After a two-year re-tendering process, a new six-year contract for administering the PSHCP was awarded to Sun Life Assurance Company of Canada on September 24, 2009. Operations under the new contract – including the launch of electronic claims processing for prescription drugs – will start following a transition period of about 14 months.
2. Why was the PSHCP contract re-tendered?
The current contract was awarded in 1995. Since that time, the health benefits industry has seen many advances and innovations that have improved service and enhanced administration. In order to ensure that the administration of the PSHCP took advantage of these advances and innovations it was decided to re-tender the contract.
3. How will the new contract benefit plan members?
The new contract for the administration of the PSHCP will introduce several improvements in terms of service and convenience for all plan members.
The most important feature for members will be the introduction of a PSHCP benefit card – also known as the pay-direct drug card. This PSHCP benefit card will enable electronic claims processing for pharmacy benefits (prescription drugs and selected medical supplies). As a result, in most cases, members will no longer have to pay the full cost of their prescription up front and then mail in a claim for reimbursement. Members only have to pay their share of the cost of each prescription.
4. Will there be any changes to benefits as a result of this new contract?
No. There will be no change to eligibility or to the benefits provided under the PSHCP as a result of the new contract. It is the way in which certain benefits are paid that will change.
For example, currently, the PSHCP allows members to assign payment for their prescriptions drugs directly to a pharmacy; members pay their share of the cost and the pharmacist bills Sun Life directly for the remainder. Since the PSHCP benefit card will enable the processing of drug claims instantaneously at point-of-sale, assignment of drug benefits will no longer be necessary and therefore this feature will no longer be available.
5. Can members use the PSHCP benefit card for claims other than pharmacy benefits?
No. The PSHCP benefit card will enable real time processing of claims for drugs and selected medical supplies (e.g. diabetic supplies) only.
Claims for all other benefits will continue to be processed the way they are now, by way of a paper claim form to Sun Life with receipts attached.
6. Why is the drug card called the PSHCP benefit card?
The drug card is called the PSHCP benefit card as it will be used for more than just electronic payment of pharmacy benefit claims. The PSHCP benefit card will include information such as the;
7. When will the PSHCP benefit card be issued?
With the recent awarding of the contract to Sun Life, a process will be undertaken to identify all members and dependants in the plan (the positive enrolment process) followed by the introduction of the new benefit card.
It is expected that by the fall of 2010, the PSHCP benefit card will be issued by Sun Life to members and those eligible adult dependents as identified by the member through positive enrolment.
8. What happens to claims between now and when the PSHCP benefit card is issued?
Until the PSHCP benefit card is issued, claims and payments will carry on under the terms of the existing PSHCP contract, which means that plan members will continue using the current paper method for the reimbursement of their drug claims. Members will therefore continue to submit their claims using the existing PSHCP claim form to Sun Life. In addition, where members have made administrative arrangements with pharmacists, these arrangements can continue until the PSHCP benefit card is introduced.
9. Why is a transition period needed?
The PSHCP benefit card relies on the electronic exchange of information. Electronic processing of prescriptions at point of sale cannot be done until significant changes are made to the systems that manage member information. That includes the modifications to Government of Canada's pay systems that provide eligibility information to Sun Life which are currently underway.
A process to support positive enrolment must also be designed and implemented by Sun Life to collect information from members about themselves and the eligible dependants they want covered. These system changes are why a transition period is required.
The government has already started making changes to its processes and systems. Sun Life estimates that it could take up to 14 months to get their systems ready, design and implement positive enrolment, and issue the PSHCP benefit card to members.
Both the bargaining agents and the Treasury Board are monitoring progress on the introduction of the benefit card and will ensure the earliest possible introduction of the new benefit card.
10. Will there be any interruption in services during the transition?
No. During the 14 month transition period, Sun Life will continue to process claims as it does now.
11. How long will this transition last and how will members be informed of progress?
Transition to the pay-direct environment is expected to take about 14 months from September 24, 2009, the date of contract award.
During the transition period, members will be provided general updates on progress through:
12. What is positive enrolment?
Positive enrolment is an important step when implementing electronic claims processing. Positive enrolment is the process where members provide information for themselves and their eligible dependants (spouse/common-law partner and each eligible child). For example, members will need to give their dependant's name, gender and age, and indicate whether they or any of their dependants have coverage under another group health plan.
It is critical that the information be up-to-date, accurate, and in an electronic format to process claims. Positive enrolment is an industry standard where drug benefit cards are used.
13. Why do members have to complete positive enrolment if they've already provided information when they joined the plan?
With drugs being paid directly with the PSHCP benefit card, the plan needs accurate electronic information about members and their eligible dependants so that electronic claims can be processed. Up to now, most of the information required to pay claims was on the PSHCP application and claim forms.
In addition, positive enrolment will provide the one time consent for the use of personal information to process all benefit requests, both electronic and paper.
14. What does "eligible dependant" mean?
Under the terms of the PSHCP, one or more persons related to a member may be eligible to participate under the plan as long as the member has family coverage and the person meets the definition of "dependant child" or "spouse" under the plan. These definitions are in the PSHCP plan document at the Treasury Board Secretariat Web site at http://www.tbs-sct.gc.ca/pol/doc-eng.aspx?id=13663 as well as on the PSHCP Administration Authority's Web site at www.pshcp.ca.
15. What about employees who want to join the plan or make changes to their coverage during the transition?
The process for joining the plan or modifying coverage levels is not affected by transition. Employees should continue to contact their compensation advisor and pensioners should continue to contact the Public Service Pension Centre in Shediac, New Brunswick at http://www.pensionetavantages-pensionandbenefits.gc.ca/cntctns-cntctus-eng.html.
16. How will plan members complete positive enrolment?
Information on how to complete positive enrolment on paper or electronically will be communicated to plan members through:
It is expected that Sun Life will begin the positive enrolment process in summer 2010.
17. What happens if some plan members choose not to enrol themselves or their dependants? Will it affect their claims?
Yes. Members who have not completed positive enrolment by the time electronic claims processing starts will have their claims returned with details on what they need to do to complete positive enrolment, on paper or electronically. Under the new contract, claims for all benefits will not be processed until the member completes positive enrolment.
18. How will the personal information of plan members be protected?
Ensuring the privacy and security of the plan members' personal information is a top priority in the transition to electronic claims processing. Both the government's information processes and systems that provide eligibility information to Sun Life and those of Sun Life that will support positive enrolment and electronic claims processing are being designed to ensure that robust safeguards are in place.
19. Why is consent for the use of personal information required to get a PSHCP benefit card?
Plan members will be asked to provide a one-time consent through the positive enrolment process. This consent will authorize Sun Life to use their personal information and the personal information of their eligible dependants to process and administer benefit claims. This consent is currently provided each time a plan member signs a paper claim form.
20. What is a per-DIN fee?
A per-DIN fee is a fixed fee that is applied to each electronic purchase of a prescription drug with a DIN number.
21. Will the PSHCP be introducing a per-DIN fee?
As part of the 2006 Memorandum of Understanding (MOU) between the Treasury Board and the Bargaining Agents of the National Joint Council along with the Federal Superannuates National Association, for the Public Service Health Care Plan (PSHCP), it was agreed that a number of cost-containment measures would be included in the agreement to offset some of the costs associated with the introduction of the PSHCP benefit card.
While a per-DIN fee was part of the list of cost-containment measures, there are no plans to proceed with the implementation of this fee at this time. In accordance with the MOU, the per-DIN fee could still be implemented in the future to offset any unexpected costs that may arise due to the implementation of this new service.