Rules of the dental care plan for the public service of Canada

Rule 1

Definition of terms

1.(1) In these rules, unless the context requires otherwise,

“accidental dental injury” (lésion dentaire accidentelle)
means an unexpected and unforeseen injury to the dental and contiguous structures of natural teeth which is a result of an event that occurs by chance, but excludes an injury associated with such normal acts as cleaning, chewing and eating;
“administrator” (administrateur)
means the organization selected to adjudicate claims, pay benefits as per the Rules of the Plan and execute certain administrative functions required for the operation of the Plan;
“Board of Management” (Conseil de gestion)
means the
  1. National Joint Council (NJC) Board, established pursuant to an agreement between the National Joint Council Unions (other than the Public Service Alliance of Canada) and the Treasury Board;
  2. Public Service Alliance of Canada (PSAC) Board, established pursuant to the Master Collective Agreement between the Public Service Alliance of Canada and the Treasury Board of Canada;
  3. Canadian Forces (CAF) Board, introduced on October 1, 1987; or,
  4. Royal Canadian Mounted Police (RCMP) Board introduced on October 1, 1987.
“child” (enfant)
means the person who is an unmarried child of a member or of the member's spouse or of the member’s common-law partner, including an adopted child, a step-child and a foster child in respect of whom the member stands in loco parentis, provided such person is

under twenty-one (21) years of age or,

under twenty-five (25) years of age and attending an accredited school, college or university on a full-time basis, or

twenty-one (21) years of age or over who is incapable of engaging in self-sustaining employment by reason of mental or physical impairment, and is primarily dependent upon the employee for support and maintenance, and provided that the child
  1. is a person to whom the above description applies on the date the employee becomes eligible for coverage or
  2. was covered as a dependant under this Plan immediately prior to his or her twenty-first (21st) birthday or
  3. was covered under this Plan as a dependant while in full-time attendance at school, college or university between the ages of twenty-one (21) and twenty-five (25).
“children's coverage” (protection d'enfant)
means coverage for eligible children;
“common-law partner” (conjoint de fait)
at the relevant time, means the person who is cohabiting with the member in a conjugal relationship, having so cohabited for a continuous period of at least one (1) year, whether this person is a same sex common-law partner or not;
“coverage of common-law partner” (protection du conjoint de fait)
means coverage as an eligible common-law partner of a member;
“coverage of spouse” (protection de l’époux)
means coverage as an eligible spouse of a member;
“dental hygienist” (hygiéniste dentaire)
means a person duly certified or licensed to perform the service rendered and shall include a dental assistant and any other similarly qualified person;
“dental mechanic” (mécanicien-dentiste)
means a person
  1. who is duly qualified to perform the service rendered and shall include a dental therapist, dentist, denturist, denturologist and any other similarly qualified person, and
  2. who practices in a province, state or country in which he or she is legally permitted to deal directly with the public;
“dentist” or “oral surgeon” (dentiste ou chirurgien-dentiste)
means a person licensed to practice dentistry by the appropriate governmental licensing authority, provided that such person renders a service within the scope of his or her license;
“dependant”
means a member’s spouse or common-law partner, or a member’s eligible child.
“effective date of the Plan” or “effective date” (date d'entrée en vigueur du régime ou date d'effet)
means March 1, 1987 (NJC component of the Plan); May 1, 1987 (PSAC component of the Plan); October 1, 1987 (CAF/RCMP components of the Plan); June 1, 1988 (employer-paid plan); and, January 1, 1991 (CAF Reserve Force component of the Plan); or, in the case of a participating employer, the effective date on which that employer is eligible to participate in the Plan as specified in Schedule 1 to these Rules.
“eligible child” (enfant admissible)
means the child of the member or of the member's spouse or of the member’s common-law partner but excludes such child who is a member of the Plan;
“eligible common-law partner” (conjoint de fait admissible)
means, at the relevant time, the common-law partner of the member as designated by the member;
“eligible employee” (employé admissible)
means an employee who satisfies the requirements of Rule 2;
“eligible service” (service admissible)
means service as an eligible employee;
“eligible spouse” (époux admissible)
means, at the relevant time, the spouse of the member as designated by the member;
“employee” (employé)
means a person who
  1. holds an office or position in or under a board, commission, corporation or other portion of the Public Service of Canada, or
  2. is a member of a group or category of persons, specified in Schedule II to these Rules, or
  3. is an employee of a participating employer.
“employer” (employeur)
means the Treasury Board of Canada;
“Employer-paid plan” (régime à la charge de l'employeur), or “the Plan”,
means the Public Service Dental Care Plan, established:
  1. pursuant to an agreement between the Public Service Alliance of Canada and the Treasury Board, introduced on March 1, 1987, as amended from time to time (PSAC component);
  2. pursuant to an agreement between the Public Service Bargaining Agents and the Treasury Board, introduced on March 1, 1987, as amended from time to time (NJC Component);
  3. by the Treasury Board, introduced on October 1, 1987 for Canadian Forces members’ dependants, Royal Canadian Mounted Police members’ dependants, and Civilian Members of the Royal Canadian Mounted Police and their dependants, as amended from time to time (CAF and RCMP components); and,
  4. by the Treasury Board, introduced on January 1, 1991 for Canadian Forces Reserve Force members and their dependants (CAF Reserve Force component).
“member” (participant)
means an eligible employee covered under the Plan;
“necessary dental treatment” (traitement dentaire nécessaire)
means a treatment rendered for the prevention of dental disease or dental defect or for the correction of dental disease, dental defect or accidental dental injury, provided such treatment is consistent with generally accepted dental practice;
“participating employer” (employeur participant)
means a board, commission, corporation or other portion of the Public Service which is specified in Schedule 1 to these Rules;
“private dental plan” (régime dentaire privé)
means the group dental plan of another employer;
“reasonable and customary charges” (frais raisonnables et habituels)
means charges for services and supplies with respect to a necessary dental treatment, of the level usually furnished in the absence of insurance for cases of the nature and severity of the case being treated and which are in accordance with representative fees and prices in the area where the treatment is rendered;
“Rules” (règlement)
means these rules with any amendments thereto in force from time to time;
“seasonal employee” (employé saisonnier)
means a person who
  1. is appointed in accordance with the Public Service Employment Act as a seasonal employee, or
  2. is appointed to perform seasonal duties for a period of less than twelve (12) months in successive years, but does not include a person who is appointed for a term in each of two (2) or more successive years;
“spouse” (époux),
at the relevant time, means the person legally married to the member, whether this person is a same sex spouse or not;
“time unit” (unité de temps)
means a fifteen (15) minute interval or any portion of a fifteen (15) minute interval;
“treatment plan” (plan de traitement)
means a written report, in a form supplied or approved by the administrator, prepared by the attending practitioner as the result of the examination of the patient and providing the following:
  1. the recommended necessary dental treatment for the correction of any dental disease, defect or accidental dental injury,
  2. the period during which such recommended treatment is to be rendered, and
  3. the estimated cost of the recommended treatment and necessary appliance;
“union” (syndicat)
means
  1. the Bargaining Agent side of the National Joint Council, as represented through the NJC Board, with respect to the Plan component introduced on March 1, 1987 for excluded employees, unrepresented employees, and employees represented by bargaining agents participating in the NJC, but excludes the Public Service Alliance of Canada; and,
  2. the Public Service Alliance of Canada, as represented through the PSAC Board, with respect to the Plan component introduced on May 1, 1987 for employees represented by PSAC.

1.(2) In these Rules, unless the context requires otherwise, where reference is made to a clause without anything in the context that a clause of some other Rule is intended to be referred to, the reference shall be deemed to be a reference to a clause of the Rule in which the reference is made.

Rule 2

Eligibility

2.(1) Every employee other than

  1. a person who is employed for a term of less than six (6) months duration (until the day following the day such person has been an employee without interruption for a period of six (6) months);
  2. a person whose assigned hours of work do not exceed one-third (1/3) of the normally scheduled daily, weekly or monthly hours of work established for a full time employee in the same occupational group;
  3. an employee whose compensation for the performance of the regular duties of his position or office consists of fees of office;
  4. an employee engaged locally outside Canada;
  5. a person employed on an "as required" basis and not assigned to work a specific number of hours; i.e. employed on a casual basis

is eligible for coverage under the Plan

2.(3) For the purpose of the completion of six (6) months continuous employment under sub-paragraph 2(1)(a), a break in service of more than seven (7) working days will interrupt the continuity.

Rule 3

Coverage

General provision

3.(1) Subject to this Rule, every eligible employee shall become covered as a member under the Plan:

  1. as of the effective date, if employed on such date, otherwise
  2. as of the day following the date of completion of three (3) months of continuous eligible service,

provided he or she qualifies as an eligible employee on that date.

3.(2) Eligible employees who are on rehabilitation leave from the Canadian Forces will not be covered under the Plan until the later of:

  1. the day following the expiration of the rehabilitation leave or
  2. the day following the completion of three (3) months of continuous employment from the employee's date of eligibility.

3.(3) Effective June 1, 1988, all eligible employees and their eligible dependants are automatically enroled in the Plan without having to complete an enrolment form.

Person on leave of absence without pay

3.(4) Where a person is on leave of absence without pay on the day he or she would under the terms of paragraph (1) become a member of the Plan, the date of coverage of such person shall be deferred to the first day of the month following the date the person resumes duty with pay as an eligible employee.

Coverage during leave without pay

3.(5)

  1. Subject to this Rule, a person to whom a leave of absence without pay is granted while he or she is a member of this Plan may continue to be a member of the Plan during such leave.
  2. Where a person to whom sub-paragraph (a) applies has been on a leave of absence without pay for a period of more than three (3) consecutive months, such person shall remit contributions in the manner and in the amount prescribed in Rule 7, except for leave of absence without pay described in sub-paragraph (b) of paragraph 1 of Rule 7.
  3. Notwithstanding sub-paragraph (a), where the contributions required to be made pursuant to sub-paragraph (b) and Rule 7 are not made, the person in respect of whom the contributions should have been made shall, subject to sub-paragraph (d), cease to be a member of the Plan on the last day of the month in respect of which the required contribution was last made.
  4. Where coverage has been discontinued in the circumstances described in sub-paragraph (c), it may only be reinstated on the first day of the month following the date the person resumes duty with pay as an eligible employee.

Member deemed eligible for coverage after lay off

3.(6)

  1. Subject to this Rule, an eligible employee who is laid off under the terms of the Public Service Employment Act or such other employment policy, while he or she is a member of this Plan, may continue to be a member of the Plan for a period of one (1) year from the date he or she was laid off.
  2. A person to whom sub-paragraph (a) applies shall remit contributions in the manner and in the amount prescribed in sub-paragraph (4) of Rule 7.
  3. Notwithstanding sub-paragraph (a), where the contributions required to be made pursuant to sub-paragraph (b) and Rule 7(4) are not made, the person in respect of whom the contributions should have been made shall, subject to sub-paragraph (d), cease to be a member of the Plan on the last day of the month in respect of which the required contribution was made.
  4. Where membership has been discontinued in the circumstances described in sub­paragraph (c), it may only be reinstated on:
    • the first day of the month following the date the person resumes duty with pay as an eligible employee, provided he or she re-enters the Public Service within one (1) year of lay-off.

Termination of coverage

3.(7) Notwithstanding any other provisions, no person shall be covered as a member of this Plan:

  1. after the date the person ceases to be an employee, if this person resigned or retired from the Public Service; or,
  2. after the date the person no longer qualifies as an eligible employee

whichever date comes first.

Re-employment

3.(8) Where an employee who was a member of the Plan ceases to be employed and again becomes employed in an eligible position three (3) months or less after termination of employment, coverage under the Plan shall resume the first day of the month following the date of re-employment.

Reinstatement as eligible employee

3.(9) An employee who ceased to be eligible for coverage under the Plan, as a result of changes to working hours or a transfer to a non-participating employer, and who subsequently becomes eligible again by starting to work more than one-third (1/3) of the standard full-time hours or with an organization participating in the Plan, shall have coverage under the Plan reinstated the first day of the month following the new date of eligibility provided that there is no break in service of more than five (5) working days immediately prior to this date.

Transfer to a position for a determinate period

3.(10) A person who was a member of the Plan immediately prior to an appointment to a position for a determinate period of less than six (6) months does not have to complete another period of three (3) months of continuous employment, as this person shall remain a member of the Plan for as long as employment continues without interruption.

Suspension

3.(11)

  1. A member under suspension may maintain coverage provided that the member pays the required contributions quarterly in advance, in the manner and in the amount prescribed in sub-paragraph (4) of Rule 7.
  2. Employer-paid coverage shall resume on the first of the month following the date the member returns to duty.

Rule 4

Coverage of spouse or common-law partner

General provision

4.(1) Subject to paragraph (2) a member becomes eligible to cover a spouse or a common-law partner under this Plan on the later of:

  1. the date the employee becomes covered as a member of this Plan, and
  2. the first date the member acquires an eligible spouse or common-law partner.

In the case of a member who ceases to have an eligible spouse or common-law partner, the member shall again become eligible for coverage on such later date, if applicable, that he or she again acquires an eligible spouse or common-law partner.

Effective date of coverage

4.(2) The coverage of the spouse or of the common-law partner of a member shall be effective on the date the coverage for the spouse or the common-law partner of the member is effective.

Termination of coverage

4.(3) The coverage of the spouse or the common-law partner of a member shall terminate on the earlier of:

  1. the date the coverage of the member terminates, and
  2. the date the member no longer has an eligible spouse or common-law partner.

Termination of coverage as a spouse or common-law partner

4.(4) Notwithstanding any other provision of this Rule, no spouse or common-law partner of a member shall be covered under this Plan:

  1. after the date he or she no longer qualifies as an eligible spouse or common-law partner under this Plan, or
  2. after the date the coverage of the member ceases,

whichever date comes first.

Rule 5

Children's coverage

General provision

5.(1) A member shall be eligible for children's coverage under this Plan on the later of:

  1. the first date the person acquires an eligible child, and
  2. the date the employee becomes a member of this Plan.

In the case of a member who ceases to have eligible children, the member shall again become eligible for children's coverage on such later date, if applicable, that he or she again acquires eligible children.

Effective date of a child's coverage

5.(2) The coverage of a child of a member shall be effective on the later of:

  1. the date he or she qualifies as an eligible child, and
  2. the date the children's coverage of the member is effective.

Notwithstanding the above provision, where coverage is on behalf of children who are covered under this Plan by the member's spouse or common-law partner, the children's coverage of such member shall be effective on the day the member submits a claim for children's coverage to the administrator.

Termination of children's coverage

5.(3) The children's coverage of a member shall terminate on the earlier of:

  1. the date the member's coverage terminates, and
  2. the date the member no longer has eligible children.

Termination of a child's coverage

5.(4) Notwithstanding any other provision of this Rule, no child of a member shall be covered under this Plan:

  1. after the day he or she no longer qualifies as an eligible child under this Plan, or
  2. after the date the coverage of the member ceases,

whichever date comes first.

Rule 6

Benefits

Definitions

6.(1) Subject to the other provisions of the Plan, in this Rule,

  1. “covered expenses” means, where permitted by law, reasonable and customary charges for the eligible dental services provided to the member, his or her covered spouse or common-law partner and his or her eligible children but, with respect to members residing in Canada, up to, but not exceeding, the amount shown in the previous year fee guide for dental practitioners and specialist fee guide where available, or such other fee guide or pricing methodology as may be adopted from time to time for the purposes of the Plan;
    1. of the province or territory where services are rendered, where such services are rendered in Canada;
    2. of the province or territory of residence of the member, where such services are rendered outside Canada.
  2. “co-insurance percentage” means that portion of covered expenses, for the applicable eligible dental services in excess of the calendar year deductible, which represents the amount of the benefit to which a member is entitled;
  3. “calendar year deductible” means, in respect of the covered expenses incurred in the calendar year for which it is being calculated, the covered expenses which, when accumulated in the order of their incurral, equal the individual deductible amount, except that not more than the combined deductible amount shall be applied in any calendar year against the covered expenses of a member and all persons to whom the coverage of the member's spouse or common-law partner or children applies.

    It is provided that, if the first dental expenses in a calendar year is incurred in the last quarter of the year (October to December), and the applicable deductible has been paid, that deductible will be carried over to the following year.

Eligible dental services

6.(2) Subject to the other provisions of the Plan, “eligible dental services” means the dental services listed hereafter when rendered by a dentist or dental specialist, or rendered by an independently licensed dental hygienist or a dental hygienist under the direct supervision of one of the above-mentioned professionals or rendered by a dental mechanic.

Where any province, state or country employs a coding of procedures for individual dental treatment which is different from that of the Canadian Dental Association, the appropriate codes of the guide of such province, state or country for the equivalent procedure shall apply. Where it cannot be ascertained that dental services rendered are eligible services, eligible services shall be such alternative services which are defined below as eligible dental services, as determined by the administrator.

  1. Diagnostic services
    1. examination and diagnostic
      • complete oral examination, once every three (3) years (36 months) (this limitation does not apply to limited new patient examinations)
      • recall oral examination, once every nine (9) months, or once every six (6) months in the case of eligible children only
      • specific oral examination
      • emergency oral examination
      • treatment planning
    2. radiographs
      • complete series of periapical films where required to support a proper course of treatment, but in no event more frequently than once every three (3) years (thirty six (36) months)
      • occlusal films
      • bitewings where required to support a proper course of treatment, but in no event more frequently than once every nine (9) months, or once every six (6) months in the case of eligible children only
      • extra-oral films
      • sialography, use of dyes
      • panoramic film, where required to support a proper course of treatment, but in no event more frequently than once every three (3) years (36 months)
      • interpretation of radiographs from another source
    3. tests, laboratory examinations
      • biopsy of oral tissue
      • pulp vitality tests
  2. Preventive services
    1. routine services
      • dental cleaning and polishing, up to once every nine (9) months, or once every six (6) months in the case of eligible children only
      • topical application of fluoride where required to support a proper course of treatment, but in no event more frequently than once every nine (9) months, or once every six (6) months in the case of eligible children only
      • pit and fissure sealants for eligible children prior to attainment of age fifteen (15)
      • caries control
      • enameloplasty
      • oral hygiene instructions once per calendar year for eligible children and once per lifetime for any other person

    Prefabricated crowns for primary teeth

    1. space maintainers (not involving movement of teeth)
  3. Restorative
    1. minor restorations
      • amalgam
      • acrylic or composite
      • pin reinforcements for these restorations
    2. Note : Replacement fillings for the same tooth and surface are covered no more than once every twenty-four (24) months for adults, and no more than once every twelve (12) months for eligible children.

    3. major restorations
      • gold foil
      • gold inlays
      • porcelain inlays
      • retention pins, posts and cores
      • crowns
      • implants
      • other restorative services
  4. Endodontics
    • pulp capping
    • pulpotomy
    • root canal therapy
    • periapical services
    • other endodontic procedures
  5. Periodontics
    • non surgical services
    • surgical services
    • post surgical treatment
    • occlusal equilibration, not exceeding eight (8) time units every year (twelve (12) months)
    • scaling and root planing, limited to six (6) times units per calendar year. In cases of documented periodontitis, up to six (6) additional time units shall be allowed in a given calendar year with the pre-approval of a treatment plan by the administrator

      Note : Application for reimbursement for scaling and/or root planing may be made for up to two (2) time units if such application is made within three (3) months of the performance of the service.

    • other periodontic services
  6. Prosthodontics
    1. minor services for removable dentures
      • repairs
      • adjustment
      • relining and rebasing, limited to once every three (3) years (thirty-six (36) months)
    2. major
      • exams, films and diagnostic casts
      • addition of a tooth to a removable denture
      • complete dentures
      • partial dentures
      • fixed bridges (abutments retainers, pontics)
      • retentive pins in abutments
      • repairs of fixed appliances
      • other prosthodontic services
  7. Oral surgery
    • uncomplicated removal
    • surgical removal and tooth repositioning
    • alveoloplasty, gingivoplasty, stomatoplasty, osteoplasty, tuberoplasty
    • removal of excess mucosa
    • surgical excision
    • removal of cyst
    • surgical incision
    • removal of impacted teeth
    • repair of soft tissue
    • frenectomy, dislocations
    • miscellaneous surgical services
  8. Orthodontic services
    1. diagnostic services
      • orthodontic exam
      • films
      • orthodontic diagnostic casts
    2. observation and adjustment
      • surgical services
      • observation and adjustment
      • repairs, alterations
    3. appliances
      • removable appliances
      • fixed appliances
      • retention appliances
      • appliances to control harmful habits
  9. Adjunctive general services
    • emergency services not otherwise specified
    • anaesthesia in connection with oral surgery and drug injections
    • consultation
    • house call, hospital call and special office visit

Specific limitations with respect to major services

6.(3) Services listed in paragraph (2):

  1. with respect to installation of prosthodontic appliances (e.g. fixed bridges, implants, partial or complete dentures, temporary or permanent), constitute eligible dental services only if they are rendered for:
    1. an initial prosthodontic appliance, or
    2. the replacement of an existing prosthodontic appliance, including the addition of teeth to an existing appliance, if
      1. the replacement, or the addition of teeth is required because at least one additional natural tooth was extracted after the insertion of the existing appliance, and the appliance could not have been made serviceable. If the existing appliance could have been made serviceable, only the expense for that portion of the replacement appliance, which replaces the teeth extracted, shall be covered;
      2. a period of sixty (60) months has passed since the previous replacement covered under the Plan, or
        • if no such coverage was provided, on initial replacement under the Plan, and once every sixty (60) months thereafter;
      3. the existing appliance was temporarily installed, provided the person was covered under the Plan when the temporary appliance was installed. The replacement appliance will thereafter be deemed permanent for the purposes of this provision;
      4. the replacement appliance is required as a result of the installation of an initial opposing denture after the date the person becomes covered under the Plan; or
      5. the replacement appliance is required as a result of accidental dental injury to a natural tooth that occurred after the date the person became covered under the Plan.
  2. with respect to crowns, the services for the replacement of a crown are eligible once every sixty (60) months from the date coverage was last provided, or, if no such coverage was provided, on initial replacement under the Plan, and once every sixty (60) months thereafter.

Amount of benefit

6.(4) Subject to the other provisions of this Rule, where a member incurs covered expenses, while covered by the Plan in respect of the person for whom such expenses are incurred, he or she shall be entitled to a benefit for all such covered expenses incurred in respect of such person in any calendar year, equal to the co-insurance percentage of those covered expenses which exceed the calendar year deductible, up to, but not exceeding the maximum reimbursement amounts for the applicable covered expenses.

Table of benefits

6.(5) For the purpose of calculating the member’s benefit under paragraph 6.(4), the co-insurance percentages, deductibles and maximum reimbursement amounts shall be as follows:

  1. Co-insurance percentages:
    • Fifty per cent (50%) for the following services
      • major restorative services (listed under provision (c)(ii) of paragraph (2))
      • major prosthodontic services (listed under provision (f)(ii) of paragraph (2)), and
      • orthodontic services (listed under sub-paragraph (h) (ii) and (iii) of paragraph (2));
    • Ninety per cent (90%) for all other services listed under paragraph (2).
  2. Calendar year deductibles:
    • individual deductible: twenty-five dollars ($25);
    • combined deductible: fifty dollars ($50).
  3. Maximum reimbursement amounts:
    1. Two thousand five hundred dollars ($2,500) for all benefits payable with respect to eligible orthodontic services (listed under sub-paragraph (h) of paragraph (2)) rendered to a covered person for the whole period while covered under the Plan;
    2. Two thousand dollars ($2,000) effective January 1, 2019; two thousand two hundred fifty dollars ($2,250) effective January 1, 2020; two thousand five hundred dollars ($2,500) effective January 1, 2021 for benefits payable with respect to eligible dental services, other than orthodontic services (referred to in the preceding provision (i)), rendered to a covered person in a given calendar year.<

    Notwithstanding the above provision, the maximum reimbursement amount for dental expenses, excluding orthodontic services, shall not exceed one thousand dollars ($1,000) effective January 1, 2019; one thousand one hundred twenty-five dollars ($1,125) effective January 1, 2020; one thousand two hundred fifty dollars ($1,250) effective January 1, 2021 in a given calendar year, if the member, his eligible spouse or common-law partner and eligible children became covered under the plan on or after July 1 of that given year.

Treatment Plan Provision

6.(6)

  1. The member should submit a treatment plan to the administrator for benefit determination when the estimated cost of a course of treatment is three hundred dollars ($300) or more.
  2. It is further provided that such treatment plan will not be considered valid if treatment does not commence within one hundred eighty (180) days of the date the treatment plan was submitted.
  3. Notwithstanding the above provision, if the treatment plan is for the purpose of allowing an additional six (6) time units of scaling and root planning in a given year in cases of documented periodontitis, the approved treatment plan for additional units will be valid for three (3) consecutive calendar years before another pre-approval is required.

Upon receipt of a treatment plan, the administrator shall advise the member of the estimated amount payable on the basis of the treatment plan estimate at the time of benefit determination.

Date an expense is incurred

6.(7) As a general rule, a covered expense shall be deemed to be incurred on the date the particular service is rendered or the supply purchased. Where multiple appointments are required for a single service, the covered expenses shall be deemed to be incurred on the date such service is complete.

Where applicable, a procedure involving the installation of an appliance shall be deemed to be completed on the date the appliance is installed. However, in the case of orthodontic services, covered expenses shall be deemed to be incurred monthly, starting with the first date the appliance is installed, and at the same date of each subsequent month falling during the treatment period.

Where the cost estimates given in the orthodontic treatment plan do not provide for specific fees with respect to the placement of the initial appliance (hereinafter referred to as “initial fee”) the amount of covered expenses incurred for each month shall be equal to the total amount of covered charges for the treatment divided by the number of months in the treatment period.

Where the cost estimates given in the orthodontic treatment plan contain fees with respect to the initial fee, the amount of covered charges incurred for each month shall be equal to:

  • with respect to the first month of treatment, the lesser of thirty-five per cent (35%) of the total amount of covered charges for the treatment and the fees shown for the initial fee;
  • with respect to subsequent months, the difference between the total amount of covered charges for the treatment and the covered charges for the first month divided by the number of subsequent months in the treatment period.

Method of Payment

6.(8) Reimbursement under this Plan shall be made in a single payment for each claim. However, in the case of orthodontic services, payments shall be made monthly, the amount of each reimbursement being equal to the benefit payable with respect to covered expenses incurred during such month, as determined under paragraph 6.(7).

Extension of benefits

6.(9) Notwithstanding any other provision of the Plan,

  1. where a person's coverage terminates because the member has terminated services with the employer or because the member or the member’s dependant is no longer eligible under the Plan, the person's coverage for the following services shall be extended for a period of thirty-one (31) days after the termination date, provided the services commenced as defined below, before such date.
    1. endodontic services, where the pulp chamber is opened before the termination date:

      services listed under sub-paragraph (2)(d) for “root canal therapy”;
    2. prosthodontic services involving an appliance for which an impression was taken before the termination date:

      services listed under sub-paragraph (2)(f) for “relining” and “addition of tooth to a removable denture”, “complete dentures” and “partial dentures”,
    3. major restorative and prosthodontic services for which a tooth was prepared before the termination date:
      • major restorative services listed under paragraph (2)(c) for “gold inlays”, “crowns”, “implants” and “other restorative services”;
      • prosthodontic services listed under sub-paragraph (2)(f) for “fixed bridges”, “retentive pins in abutments” and “repairs of fixed appliances”.
    4. ongoing orthodontic treatment where the initial appliance was placed before the termination date. (Effective July 1, 2000)

Conditions for benefit payment

6.(10)

  1. A member entitled to a benefit under the Plan must submit to the administrator notice and proof of claim satisfactory to the administrator within the time period indicated in sub-paragraph (b).
  2. Written notice and proof of claim must be furnished to the administrator within fifteen (15) months of the date the expense is incurred or deemed to be incurred under the Plan. Failure to provide the notice and proof within the time required shall not invalidate nor reduce any claim if it was not reasonably possible to give proof within such time, provided such proof is furnished as soon as reasonably possible and in no event, except in the case of legal incapacity, later than twenty-four (24) months after the expense was incurred.

Coordination of benefits

6.(11)

  1. All covered expenses shall be subject to coordination of benefits as defined in this paragraph.
  2. For the application of this paragraph, “allowable expense” means any reasonable and customary item of expense at least a portion of which is covered under at least one of the Plans covering the person for whom claim is made.
  3. This paragraph shall apply in determining the benefits as to a person covered under this Plan for any calendar year if, for the allowable expenses incurred as to such person during such year, the sum of the benefits that would be payable under this Plan in the absence of this paragraph, and the benefits that would be payable under all plans, including this Plan in the absence therein of provisions of similar purpose to this paragraph, would exceed such allowable expenses.
  4. As to any calendar year with respect to which this paragraph is applicable, the benefits that would be payable under this Plan in the absence of this paragraph for the allowable expenses incurred as to such person during such calendar year shall be reduced to the extent necessary so that the sum of such reduced benefits and all the benefits payable for such allowable expenses under all plans, including this Plan except as provided under sub-paragraph (e) below, shall not exceed the total of such allowable expenses. Benefits payable under another plan include the benefits that would have been payable had claim been duly made therefor.
  5. If
    1. another plan which is involved in sub-paragraph (d) of this paragraph and which contains a provision coordinating its benefits with those of this Plan would, according to its rules, determine its benefits after the benefits of this Plan have been determined, and
    2. the rules set forth in sub-paragraph (f) of this paragraph would require this Plan to determine its benefits before such other plan,

    then the benefits of such other plan shall be ignored for the purpose of determining the benefits under this Plan.

  6. For the purpose of sub-paragraph (e) of this paragraph, the rules establishing the order of benefit determination are:
    1. benefits shall be determined first under the plan which covers the person for whom expenses have been incurred
      • other than as a spouse, common-law partner or child, or
      • as a child of the person whose date of birth, excluding year of birth, is earlier in the calendar year;
    2. subject to provision (iii) below, where rules specified in (i) do not establish an order of benefit determination, or another plan contains different rules, benefits will be pro-rated between or amongst the plans in proportion to the amounts that would have been paid under each plan in the absence of other coverage;
    3. notwithstanding (ii), where the other Plan is the Public Service Health Care Plan (PSHCP), benefits shall be determined first under the PSHCP for allowable expenses on account of accidental dental injury and first under this Plan for allowable expenses with respect to oral surgery.
  7. When this provision operates to reduce the total amount of benefits otherwise payable as to a person covered under this Plan during any calendar year, each benefit that would be payable in the absence of this paragraph shall be reduced proportionately, and such reduced amount shall be charged against any applicable maximum reimbursement amount of this Plan.
  8. For the purpose of determining the applicability of, and implementing the terms of this paragraph or of any provision of similar purpose of any other plan, the administrator may without the consent of, or notice to any person, release to or obtain from any other insurance company or other organisation or person any information, with respect to any person, which the administrator deems to be necessary for such purposes. Any person claiming benefits under this Plan shall furnish to the administrator such information as may be necessary to implement this provision.

Covered expenses limitations

6.(12) Expenses incurred for the following shall in no event be covered expenses:

  1. services and supplies, or any portion thereof, which are covered under any provincial, territorial or other public dental, hospital or health plan to which the person is eligible;
  2. services and supplies, or portion thereof, which are the legal liability of any other party;
  3. services and supplies, rendered or provided to which a person is entitled without charge pursuant to any law including, but not limited to Workers' Compensation or similar law, or for which there is no cost to the person except for the existence of insurance against such cost;
  4. services and supplies received in a hospital owned or operated by a government, unless the person is required to pay for such services or supplies regardless of the existence of insurance;
  5. services and supplies rendered outside Canada to persons residing in Canada or to children of a member residing in Canada, which would be payable under a provincial health, dental or hospital plan if the services had been rendered in Canada;
  6. dental treatment involving the use of precious metals, if such treatment could have been rendered at lower cost by means of a reasonable substitute consistent with generally accepted dental practice, except for that portion of expenses which would have been incurred for treatment by means of a reasonable substitute;
  7. user fees, co-insurance charges or similar charges which are in excess of charges payable by a governmental dental, hospital or health plan;
  8. dental treatment which is not yet approved by the Canadian Dental Association or which, in the opinion of the administrator, is clearly experimental in nature;
  9. services and supplies which, in the opinion of the administrator, are rendered principally for cosmetic purposes including, but not limited to, porcelain or composite facings on crowns or pontics on molar teeth;
  10. services and supplies related to the purchase, repair, modification or replacement of a duplicate prosthodontic appliance, for any reasons;
  11. services rendered and supplies purchased prior to the date the person became covered under this Plan;
  12. charges for an appliance or a modification of one where an impression is made for such appliance or modification before the person became covered under this Plan; charges for crowns, bridges and gold restorations for which a tooth was prepared before the person became covered under this Plan; charges for root canal therapy where the pulp chamber was opened before the person became covered under this Plan;
  13. services and supplies rendered as a result of a congenital or developmental malformation which is not a Class I, II or III malocclusion, except for a child under twenty-one (21) years of age;
  14. charges for a periodontal appliance, occlusal equilibration, and other related dental services or supplies as a result of a temporo-mandibular joint dysfunction (TMJ dysfunction) or vertical dimension correction;
  15. charges for an orthodontic treatment, in respect of a member or his or her eligible spouse or common-law partner, where the initial appliance was installed before the person became covered for such service under this Plan;
  16. charges for trauma control if done at the same time as a treatment for caries or pain control;
  17. charges for the enlargement of the canal or pulp chamber as part of a dental treatment;
  18. charges for a dental professional peer consultation;
  19. charges for the assistance of a second oral surgeon.

Appeals

6.(13)

  1. When a member is seeking to appeal the decision of the administrator to decline a claim, the member shall appeal that decision with the administrator as a first resort.
  2. If there is no resolution between the member and the administrator at first resort, a member may then submit an appeal case to the appropriate Board of Management.
  3. The Board of Management shall endeavour to hear the case in as expeditious a manner as possible.

Rule 7

Contributions

7.(1)

  1. The full cost of the Plan shall be paid by the Employer.
  2. Notwithstanding paragraph (a), during any period where a member is on leave of absence without pay for reasons other than:
    1. for the purpose of undergoing training or instruction to the advantage of the employer,
    2. for the purpose of serving with the Canadian Forces other than as a member of the regular force,
    3. because of pregnancy, illness or disability,
    4. to serve with an organization when the service is to the advantage of the department or, is being performed at the request of the government of Canada,
    5. parental leave for care and nurturing which occurs up to fifty-two (52) weeks after the birth or adoption of the child,
    6. the first three (3) consecutive months of any period of leave without pay,
    7. for the leave portion of the leave with income averaging arrangement,
    8. for the leave portion of the pre-retirement leave arrangement

this member, subject to certification of such absence by the appropriate deputy head, shall bear the full monthly cost in accordance with paragraph 7.(3) for the coverage on such basis as may be determined from time to time.

Seasonal Lay-off

7.(2) Members proceeding on seasonal lay-off shall have continued coverage paid by the employer for the duration of the seasonal lay-off.

Members' contributions

7.(3) Members who proceed on leave of absence without pay as referred to in sub­paragraph 1(b) of Rule 7, shall remit contributions in advance on a quarterly basis, from the first (1st) of the fourth (4th) month following the month in which the leave began.

7.(4) Members who are laid off as referred to in sub-paragraph 7(b) of Rule 3, or suspended as referred to in sub-paragraph 11(a) of Rule 3, shall remit contributions in advance on a quarterly basis, from the first (1st) of the month following the month in which the lay-off or suspension period began. Such eligible members shall be provided with reasonable notice to remit such contributions.

Rule 8

General provisions

Amendments

8.(1) The employer and the unions have the right to enter into an agreement to modify or amend the provisions and Rules of the Plan, which were established by Treasury Board decision on December 11, 1986 based on the agreement reached between the employer and the unions of the National Joint Council (NJC) as well as the conciliation decision between the Public Service Alliance of Canada and the Treasury Board dated October 29, 1986.

Directives

8.(2) The employer may, at any time and from time to time, make directives which may be required to provide for the proper administration of the Plan. These directives shall be consistent with the provisions of the Plan.

Rights and limitations

8.(3) The establishment of the Plan shall not be construed as conferring any legal rights upon any employee or other person for continuation of employment, nor shall it interfere with the rights of the employer to discharge any employee and to treat him or her without regard to the effect which such treatment might have upon him or her as a member of the Plan.

Non-alienation of benefits

8.(4) No benefit under the Plan shall be subject in any manner to anticipation, alienation, sale, transfer, assignment, pledge encumbrance or charge, and any attempt to do so shall be void, except as specifically provided in the Plan, nor shall any such benefit be in any manner liable for or subject to garnishment, attachment, execution or levy, or liable for or subject to the debts, contracts, liabilities, engagements or torts of the person entitled to such benefit.

No benefit under the Plan shall be subject to assignment, except for assignment to the treating dentist as directed by the member.

Beneficiaries

8.(5) All benefits under this Plan are payable to the member or to his or her spouse or common-law partner if so directed by the member. Any benefits unpaid at the member's death may at the option of the administrator, be paid either to the beneficiary or to the estate of such person.
If a benefit under this Plan shall be payable to the estate of the member or to a member who is a minor or otherwise not competent to give a valid release, the administrator may pay such benefit to any relative by blood or connection by marriage of the member or to a person appearing to the administrator to be equitably entitled thereto by reason of having incurred expenses for the maintenance, care or treatment of the member or the member's dependant. Any payment made by the administrator in good faith pursuant to this provision shall fully discharge the Plan with respect to such payment.

Schedule I

Participating Employers

  • Atlantic Pilotage Authority (January 1, 1988)
  • Atomic Energy of Canada Limited (May 11, 2015)
  • Canada Investment and Savings (previously Canada Retail Debt Agency) (July 15, 1996)
  • Canada Revenue Agency (previously Canada Customs and Revenue Agency (November 1, 1999)
  • Canadian Centre for Occupational Health and Safety (April 1, 1989)
  • Canadian Council of Ministers of the Environment (April 1, 1991)
  • Canadian Food Inspection Agency (March 20, 1997)
  • Canadian High Arctic Research Station (June 1, 2015)
  • Canadian Institutes of Health Research (previously Medical Research Council of Canada) (January 1, 1988)
  • Canadian Museum of Human Rights (September 1, 2009)
  • Canadian Museum of Nature (July 1, 1990)
  • Canadian Nuclear Safety Commission (previously Atomic Energy Control Board) (January 1, 1988 and May 11, 2015)
  • Canadian Polar Commission (April 7, 1992)Canadian Security Intelligence Service (January 1, 1988)
  • Communications Security Establishment (January 1, 1988)
  • Federal Public Sector Labour Relations and Employment Board (previously Public Service Staff Relations Board) (March 1, 1987)
  • Financial Consumer Agency of Canada (August 24, 2001)
  • Financial Transactions and Reports Analysis Centre (July 5, 2000)
  • Great Lakes Pilotage Authority (January 1, 2000)
  • House of Commons (January 1, 1988 and October 1, 1988)
  • Indian Oil and Gas Canada (January 1, 1988)
  • Laurentian Pilotage Authority (January 1, 1988)
  • Library of Parliament (January 1, 1988 and January 1, 19889)
  • National Battlefields Commission (February 1, 1989)
  • National Capital Commission (March 1, 1987)
  • National Energy Board (March 1, 1987)
  • National Film Board (January 1, 1988)
  • National Gallery of Canada (July 1, 1990)
  • National Museum of Science and Technology (July 1, 1990)
  • National Research Council of Canada (July 31, 1987)
  • National Security and Intelligence Committee of Parliamentarians (September 1, 2017)
  • National Trust for Canada (previously Heritage Canada (January 1, 1988)
  • Natural Sciences and Engineering Research Council (January 1, 1988)
  • Northern Pipeline Agency (January 1, 1990)
  • Office of the Auditor General of Canada (June 1, 1988)
  • Office of the Conflict of Interest and Ethics Commissioner (November 4, 2004)
  • Office of the Correctional Investigator (January 1, 1988)
  • Office of the Superintendent of Financial Institutions (June 1, 1988)
  • Parks Canada Agency (December 28, 1998)
  • Parliamentary Centre for Foreign Affairs and Foreign Trade (January 1, 1990)
  • Security Intelligence Review Committee (January 1, 1988)
  • Senate of Canada (January 1, 1988)
  • Social Sciences and Humanities Research Council (January 1, 1988)
  • Social Security Tribunal of Canada (December 15, 2016)
  • Telefilm Canada (previously Canadian Film Development Corporation (January 1, 1990)

Schedule II

Group or Category of Persons

  • Governor in Council Appointees
  • Governor General
  • Lieutenant Governors
  • Members of the House of Commons
  • Members of the Senate
  • Members of Parliament Staff
  • Ministers' Exempt Staff (appointed pursuant to the Public Service Employment Act)
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