Public Service Dental Care Plan member booklet

When does your coverage start?

Once you become an eligible employee, membership and coverage under the PSDCP start after exactly 3 months of continuous employment. Coverage is extended to the employee’s eligible dependants on the same date, and, from then on, new dependants’ dental coverage will start on the date they become eligible dependants.

If you are on leave without pay or on a seasonal layoff on the day that you would normally have become a member of the plan, your coverage and the coverage for your eligible dependants will begin on the first day of the month after the month you resume paid work (for example, if you resumed paid work on October 15, your coverage would begin on November 1).

Who is covered?

Seasonal employees

Once you are a member of the PSDCP, even if you are a seasonal employee, you will have year-round coverage, including when you are on seasonal layoff.

Leave without pay

Before taking leave without pay, you are responsible for:

• notifying Compensation Services in your department or the Public Service Pay Centre about the details of your leave
• arranging for the quarterly payment of your monthly contributions in advance, if necessary, before your coverage ends

Compensation Services in your department or the Public Service Pay Centre will provide you with a letter that describes what you have to do to maintain continuous coverage.

If you go on authorized leave without pay for any of the following reasons, you will retain your employer-paid coverage during your absence:

• maternity leave or parental leave (within 52 weeks of the birth or adoption of a child)
• sick leave without pay
• disability or long-term disability leave
• educational leave without pay at the request of the employer
• leave to serve in another organization if doing so is recognized as being to the advantage of the department or to the Government of Canada
• leave for training or other activities as part of service in the CAF or Reserves
• leave taken as part of leave with income averaging and pre-retirement transition leave

If you proceed on any other type of leave without pay:

• your employer-paid coverage will continue during the first 3 consecutive calendar months of leave
• as of the 4th month of your leave of absence, if you wish to keep your coverage, you must pay your monthly contribution amount (including the applicable provincial sales tax) in advance to the Receiver General for Canada on a quarterly basis
  • It is recommended that you pay your contributions before the beginning of the quarterly period to avoid any disruptions in your coverage
• continue your quarterly payments for the duration of your leave without pay, including the month when you return to work (see Paying contributions)
  • Unlike the Public Service Health Care Plan, if you do not pay the required quarterly contributions in advance, your PSDCP coverage will be suspended until the first of the month following the month that you return to work

Retroactive reinstatement of coverage for you or your eligible dependants is not possible while you are on leave without pay if your monthly contributions have not been paid in advance on a quarterly basis. If your coverage ceases, it can only be reinstated on the first of the month following the month that you return to work.

Example

You take leave without pay from February 21, 2019 , to November 3, 2019 , because your spouse needs to relocate. You return to work on November 5, 2019 .

First 3 months

You have employer-paid coverage for the first 3 full months of your leave without pay (March, April and May 2019). This coverage stops on May 31, 2019 .

Before the end of the third month

You must send your contributions in advance on a quarterly basis for the period beginning on June 1, 2019 , if you wish to have continuous coverage for the rest of the period of your leave without pay. Your quarterly contributions are required before June and October for the period of June through November of 2019 inclusively. Otherwise, your coverage will be suspended until after you return to work.

Return to work

Your employer-paid coverage is reinstated as of December 1, 2019 (the first of the month following the month that you return to work).

Termination of coverage

Your PSDCP membership ends automatically on the date when you cease to be an eligible employee or on the date when you cease to qualify as an eligible employee. For example, if you become a part-time employee and work one third (1/3) or less of the normally scheduled hours of a full-time employee in the same occupational group, your coverage will end.

Your spouse or common-law partner is no longer covered by the plan when this person ceases to be your spouse or common-law partner, or when you are no longer an eligible member of the PSDCP, whichever comes first. You are responsible for immediately communicating such changes to Canada Life.

Your child is no longer covered by the plan when they no longer meet the definition of an eligible child, or once you are no longer a member of the PSDCP, whichever comes first. The children of your common-law spouse are no longer covered when your common-law relationship ends.

When and how to report changes that affect dental coverage

You are responsible for notifying Canada Life and Compensation Services in your organization if you work for a separate employer, in writing, as soon as possible when there are changes in your personal circumstances that could affect your coverage. Changes that could affect your coverage include:

• you are divorced from your spouse or are no longer living with your common-law partner
• you have a new spouse or common-law partner
• your dependent children are between 21 and 25 years old and they have completed or changed their school attendance from full-time to part-time

It is important to note that the changes would also need to be communicated separately to the Public Service Health Care Plan.

Canada Life will issue you an identity card once you become a plan member under the National Joint Council or the Public Service Alliance of Canada components. If you are a CAF Reservist, you will receive your card once your first claim is received. This card shows:

• the effective date of your coverage
• your plan number
• your certificate number

You will use your plan number and certificate number to identify yourself and your eligible dependants to Canada Life and to your dentist when you submit a claim. Your plan number and certificate number must be included:

• on all claims submitted for yourself and your eligible dependants
• in all correspondence with Canada Life

Should you lose your identity card, contact Compensation Services in your department or the Public Service Pay Centre to get your plan and certificate numbers.

General description

The PSDCP covers:

• specific services and supplies that are not covered under a provincial health or dental plan
• only reasonable and customary charges for dental treatment that is needed to prevent or correct dental disease or defect, if the treatment is consistent with generally accepted dental practices

Reasonable and customary charges mean:

• the amount usually charged to someone without insurance coverage
• an amount that does not exceed the general level of charges for the specific service in the place where it was performed

Canada Life bases the amounts covered on the appropriate provincial or territorial dental association fee guide.

A dental association fee guide is a listing of charges established by the respective provincial or territorial dental association for specified services provided by a specific practitioner type in a province or territory. It is common practice to reimburse eligible dental expenses using the fee guide that was in effect for the previous year.

For services rendered in Canada, the PSDCP will reimburse eligible expenses incurred for dental services performed by a dental practitioner who is licensed to provide dental services in the province or territory where the service is received. Services provided by the following professionals are covered:

• dentists, dental specialists or dental mechanics
• denturists or denturologists
• an independently licensed dental hygienist or a dental hygienist under the direct supervision of 1 of the above‑mentioned professionals
• anaesthetists (in connection with oral surgery and drug injections)

Annual deductible

The annual deductible is a specific amount that is subtracted from your reimbursement each calendar year before you are reimbursed on your first claim. The annual deductible amount is $25 per covered person and not more than $50 for a family.

Copayments

After you have paid the annual deductible amount, the plan will reimburse a percentage of any eligible expense. The percentage that is not covered by the PSDCP and that you have to pay is called the copayment. The table below shows your copayments depending on the service received.

Important: You must pay any portion not reimbursed by the PSDCP, even in cases where the dental practitioner charged you more for a given service or procedure than the amount specified in the applicable dental association fee guide for the previous year.

Annual maximum reimbursement amount

For eligible expenses incurred in a calendar year, the PSDCP will reimburse you up to an annual maximum of:

• $2,000 between January 1, 2019 , and December 31, 2019
• $2,250 between January 1, 2020 , and December 31, 2020
• $2,500 after January 1, 2021

Important: This maximum excludes orthodontic services, which have a separate lifetime maximum.

If your coverage starts in the second half of the year (on or after July 1), you or your eligible dependant will be reimbursed up to the following maximum for expenses incurred in the rest of this first calendar year:

• $1,000 between July 1, 2019 , and December 31, 2019
• $1,125 between July 1, 2020 , and December 31, 2020
• $1,250 after July 1, 2021

The full annual maximum will apply in the next calendar year.

Lifetime limit for orthodontic services

Orthodontic services are subject to a separate lifetime maximum of $2,500 for each covered person.

Treatment plan

Before beginning a treatment or procedure that is expected to cost more than $300 and for all orthodontic treatments, you or your dentist must submit an estimate of the proposed work to Canada Life. Canada Life will send you a predetermination of benefits statement to let you know:

• if the work is covered by the plan
• how much will be covered when there is no coordination of benefits

In some cases, the treatment may not be covered, but an alternative treatment may be allowed. The PSDCP’s alternative benefit clause (ABC) allows coverage of a less expensive, reasonable and customary dental service. An ABC is not applied in all cases: for example, if you choose an onlay where a filling would have been considered a viable treatment option, no benefits will be paid toward the cost of the onlay.

In other cases, time restrictions may apply. For example, if you have received reimbursement under the ABC for a partial toward an implant, you will only be eligible for a new partial or implant after a period of 60 months.

Scaling and root planing services are limited to 6 units per calendar year, but in cases of documented periodontitis, up to 6 more units can be allowed in that year with the pre-approval of a complete treatment plan submitted by your dentist.

Important: A predetermination of benefits statement may indicate that a treatment or service is eligible, but there may be limitations or time restrictions that apply. Ensure that you or your dependants have not exceeded the yearly maximum reimbursement amount before you incur more expenses. There may also be an age limit for certain services like pit and fissure sealants. Read all of the notes and remarks included in Canada Life’s predetermination of benefits statement, which is valid for 6 months (or 180 days) if you are still covered by the PSDCP.

Preventive and basic dental services and supplies are reimbursed at 90% with certain conditions^{Footnote 3}

Diagnostic services (excluding services related to major prosthodontic), such as:

• examinations
• X-rays
• tests and laboratory reports (including diagnostic services related to orthodontic treatment)

Preventive services, such as:

• dental cleaning and polishing
• topical application of fluoride
• pit and fissure sealants
• oral hygiene instruction
• space maintainers

Minor restorative services, such as:

• amalgam
• acrylic
• composite fillings

Endodontics, such as:

• pulp capping
• root canal therapy

Periodontics, such as:

• gum treatments
• scaling and root planing

Minor prosthodontic services (also known as removable dentures), such as:

• denture repairs and adjustments
• denture relining
• denture rebasing

Surgery, such as:

• extractions of teeth
• other surgical procedures

Adjunctive services, such as:

• other emergency services not otherwise specified
• anaesthesia
• house calls or hospital calls

Major dental procedures and orthodontic services are reimbursed at 50% with certain conditions^{Footnote 4}

Major restorative services, such as:

• gold foil restorations
• metal and porcelain inlays
• onlays
• implants and crowns

Major prosthodontic services, such as:

• diagnostic services
• complete and partial dentures
• fixed bridges (abutments or retainers, pontics)
• repairs of fixed appliances

Orthodontic services, such as:

• surgical services
• observation and adjustments
• fixed appliances
• removable appliances

Submitting your claims

You must submit your claims to Canada Life online through the PSDCP Member services website, through your dental office or by mail:

• within 15 months of the date on which the expense was incurred
• for orthodontic treatment, within 15 months of the date of each monthly visit throughout the treatment period

Claims submitted after the 15-month period will not be paid unless you can demonstrate that it was impossible for you to submit your claim within 15 months.

Important: Claims submitted more than 24 months after the expense was incurred will not be paid except in the case of legal incapacity.

Online

You can submit claims electronically through Canada Life’s PSDCP Member services website^{Footnote 5}. You will need your plan and certificate numbers (available on the PSDCP benefit card) to access the site or the service number for CAF dependants or the regimental number for RCMP members and their dependants. On the PSDCP Member services website, you can also find information about your benefits, including how to:

• sign up for direct deposit so that payments from Canada Life can be deposited directly into your bank account
• access information about your coverage
• complete and print personalized dental claim forms
• view and print your claim summaries to track your claim history and use for income tax purposes when you claim dental expenses that are not covered by the plan
• view the status of your claims and your explanation of benefits statements for the last 24 months
• check your dental care coverage balance and when you and your dependants are eligible for your next checkup
• upload a photocopy, scanned document or a picture of your claim directly

For claims submitted electronically by the dental office, it is your responsibility to:

• authorize your dentist to submit claims
• ensure that your personal information, including your plan number, certificate number and address, is correct and current

By mail

If your expenses are eligible for reimbursement, you must complete and submit an authorized claim form with the appropriate information, including:

• your full name and address, including your postal code
• your plan and certificate numbers
• your spouse or common-law partner's dental plan and certificate number, if applicable
• your signature
• the appropriate section of the claim form completed by your dentist

Incomplete forms will be returned to you for completion. Attach any bills or receipts that you may have and ensure that they provide full details of the services rendered or purchases made.

All paper claims should be mailed to Canada Life, to one of the following mailing addresses.

For Canadian residents except residents of Quebec:

Winnipeg Benefit Payments
P.O. Box 6025 Station Main
Winnipeg MB
Canada
R3C 3C7

For Quebec residents, other than the National Capital Region:

Montreal Benefit Payments
Place Bonaventure
800 de la Gauchetière Street West
Suite 5800
Montreal QC
Canada
H5A 1B9

For employees residing outside Canada:

Canada Life Health & Dental Benefits
Foreign Benefit Payments
P.O. Box 6000
Winnipeg MB
Canada
R3C 3A5

How to coordinate your claims

If you are a member of the PSDCP and are also covered under your spouse or common-law partner’s plan as an eligible dependant, you should submit your claim to your own plan first.

If your spouse or common-law partner is covered under another plan and is also covered as an eligible dependant under your plan, your spouse or common-law partner should submit their expenses to their own plan first.

When your children are covered under both your plan and your spouse or common-law partner’s plan as eligible dependants, the plan that pays first is determined by the Canadian Life and Health Insurance Association guidelines for coordination of benefits. Under these guidelines, the parent whose birthday falls earlier in the year must claim the children’s expenses first under their plan.

In case of divorce or separation, where both parents share custody of a child, the following order of submission must be followed for the child’s expenses:

1. the plan of the parent whose birthday falls earlier in the year
2. the plan of the parent whose birthday comes later in the year
3. the plan of the spouse or common-law partner of the parent whose birthday falls earlier in the year
4. the plan of the spouse or common-law partner of the parent whose birthday comes later in the year

If 1 parent has custody of a child, the following order of submission must be followed for the child’s expenses:

1. the plan of the parent who has custody of the child
2. the plan of the spouse or common-law partner of the parent who has custody of the child
3. the plan of the parent who does not have custody of the child
4. the plan of the spouse or common-law partner of the parent who does not have custody of the child

If you do not have care and custody of your child or children, you may authorize the person who does have care and custody of the child or children to file claims and receive payment for the eligible child or children’s dental services.

To authorize direct payment to the person who has custody of the child or children, complete and submit to Canada Life the Public Service Dental Care Plan Authorization for Claims Submission and Redirection of Payment form.

Should you later wish to rescind this authorization, you may do so by writing to Canada Life.

Coordinating benefits for members of plans administered by Canada Life

If you and your spouse or common-law partner are both members of the PSDCP or if Canada Life administers both of your plans, follow the process noted above to determine which plan you should submit your expenses to first. You do not need to submit a second claim for the unpaid balance if you indicate the plan and certificate numbers of your spouse or common-law partner’s dental plan on the claim form, as Canada Life will process the eligible claims under both memberships.

Claims made under your spouse or common-law partner’s plan and certificate numbers will be paid out to them unless the benefits are assigned to the dentist.

Payment of your claim

Once your claim has been assessed under your certificate number, you will receive an explanation of benefits with your benefit payment, if applicable, from Canada Life. Payment will be issued to you or, if you have signed the Public Service Dental Care Plan  Authorization for Claims Submission and Redirection of Payment form for your children’s claims, payment may be issued to your spouse or common-law partner or to the dentist.

Payments are normally made in a lump sum once the treatment has been performed with the exception of payments for orthodontic services. For orthodontic services, you will be reimbursed on a monthly basis if a claim form is submitted for the monthly adjustment or if you have prepaid for the treatment in full. To ensure that you are still eligible for reimbursement, it is recommended that you regularly submit a confirmation of your ongoing treatment using the Public Service Dental Care Plan Claim form. The calculations for these payments will be based on the information submitted by the orthodontist as described on the predetermination of benefit statement issued by Canada Life.

How to appeal an assessment

Occasionally, you may disagree with a claim assessment made by Canada Life. You can always resubmit your claim and ask Canada Life to review the claim internally. If, after asking Canada Life to review, the issue cannot be resolved, you may refer the issue to the Board of Management responsible for your component at the address indicated below.

When referring the matter to the relevant Board of Management, you, or through Compensation Services in your department or your bargaining agent, must provide all the facts of the case. Make sure to include the details related to your appeal, your plan number, your ID number, and your coordinates and send your appeal to the appropriate address below.

If you are represented by the Public Service Alliance of Canada (PSAC):

If you are a member of the Canadian Armed Forces or the Reserves:

If you are a member of the RCMP:

For all other members: