Public Service Dental Care Plan member booklet

Who is covered by the Plan

The Public Service Dental Care Plan (PSDCP) covers all eligible federal public service employees, employees of a number of separate employers and their eligible dependants.

When coverage starts

When you become eligible, membership and coverage under the Public Service Dental Care Plan (PSDCP) begins following exactly three (3) months of continuous employment. Coverage is extended to the employee's eligible dependants on the same date.

New dependants have dental coverage from the date they become eligible dependants.

If you are on Leave Without Pay or on seasonal lay-off on the day you would normally have become a member of the Plan, your coverage will begin the first day of the month after the month you resume duty with pay. Coverage for your eligible dependants will also begin on that date.

Seasonal employees

Once in the Plan, seasonal employees have continuous year-round coverage, including the time while on seasonal lay-off.

Leave without pay

If you go on authorized Leave Without Pay for any of the following reasons, employer-paid coverage will be extended to you for the total period of absence:

• maternity leave;
• parental leave (within the 52-week period following the birth or adoption of a child);
• sick Leave Without Pay or disability;
• educational Leave Without Pay at the request of the employer;
• leave to serve with another organization recognized as being to the advantage of the department or to the Government of Canada;
• leave to serve with the Canadian Forces and Reserve Forces training /activities; and
• the leave portion of Leave with Income Averaging and Pre-retirement Transition Leave.

If you proceed on any other type of Leave Without Pay, employer-paid coverage will continue during the first three consecutive calendar months of leave. Following this period, if you would like to maintain your Public Service Dental Care Plan (PSDCP) coverage, you must pay contributions (including applicable provincial sales tax) quarterly in advance, starting with the fourth (4th) month of your leave of absence and continuing for the duration of the Leave Without Pay, including the month you return to work. A table of monthly contributions is included in Appendix A.

Prior to taking a Leave Without Pay, you are responsible for notifying your departmental Compensation Office or the Public Service Pay Centre of the details regarding your leave and to arrange to pay your contributions quarterly in advance, when required. Your departmental Compensation services or the Public Service Pay Centre will provide you with a letter describing your responsibilities for maintaining continuous PSDCP coverage.

Employer-paid coverage will not resume until the first of the month following your return to work. Please note that this is not the same as the Public Service Health Care Plan (PSHCP).

Example

e.g. You take a Relocation of Spouse Leave Without Pay from February 21, 2012 to November 3, 2012 and return to work on November 5, 2012.

You have employer-paid Public Service Dental Care Plan (PSDCP) coverage through the first three full months of Leave Without Pay (March, April and May 2012). This employer-paid coverage will cease on May 31, 2012.

You must remit contributions in advance on a quarterly basis for the period beginning June 1, 2012 if you wish to have continued PSDCP coverage throughout the remaining period of Leave Without Pay. Contributions would be required for June through November of 2012 (inclusively) as employer-paid coverage would not be reinstated until December 1, 2012 (the first of the month following the month you return to work).

Termination of coverage

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

Your spouse or common-law partner is no longer covered by the Plan when he or she ceases to be your spouse or common-law partner, or when you are no longer a member of the Plan, whichever date is earlier.

Your child is no longer covered by the Plan when he or she ceases to be an eligible child (for example a child reaches 21 years of age, or age 25 if in full-time attendance at a recognized educational institution) or when you are no longer a member of the Plan, whichever date is earlier.

Note:

If you have Public Service Dental Care Plan (PSDCP) coverage and you are laid off, dental coverage may be continued for a period of up to one year provided you pay the full cost of contributions. An exception to this Rule occurs when a dental treatment requiring more than one sitting began while you or your eligible dependants were in the Plan; coverage for that treatment will continue if it is completed within 31 calendar days of the termination date. Examples include root canal treatment where the pulp chamber is opened prior to termination, a crown where the tooth is prepared and impressions are taken prior to termination of coverage, or ongoing orthodontic treatment where the initial appliance was inserted prior to the termination date. Please contact your Compensation Advisor for further details regarding your eligibility in these circumstances. If your coverage is terminated due to retirement, you may be eligible to apply for coverage under the Pensioners' Dental Services Plan.

Reporting changes affecting coverage

As the plan member covered under the Public Service Dental Care Plan (PSDCP), you are responsible for notifying Great-West Life, in writing, when there are changes to your personal circumstances that could affect your coverage. Contact information is located in Appendix D.

Examples of changes affecting coverage:

• Spouse/common-law partner, no longer eligible dependant;
• New spouse/common-law partner; and
• change in school attendance for dependants between 21 and 25 years of age.

Once you become a plan member, Great-West Life will issue you an identity card. This card indicates the effective date of your coverage, the plan number and your certificate number you will use to identify yourself and your eligible dependants to Great-West Life when you file your claims. You must record the plan number and your certificate number on all claims submitted for yourself and your eligible dependants, and on all correspondence with Great-West Life.

Should you lose your identity card, please contact your departmental Compensation services or the Public Service Pay Centre to obtain a replacement card.

General description of the coverage

The Public Service Dental Care Plan (PSDCP) provides coverage for specific services and supplies that are not covered under a provincial health or dental care plan. Further, the Plan covers only reasonable and customary dental treatment, necessary to prevent or correct dental disease or defect, provided the treatment is consistent with generally accepted dental practices.

The Plan will reimburse Members for eligible expenses incurred for dental services performed by:

• dentists, dental specialists or dental mechanics;
• denturists or denturologists;
• dental hygienists if the dental service is performed in a province or territory of Canada in which dental hygienists are licensed to provide such services (otherwise, under the direct supervision of a dentist or dental specialist);
• anaesthetists (in connection with oral surgery and drug injections).

The dental practitioner must be licensed to provide dental services in the province or territory where the service is received.

Reasonable and customary

Reasonable and Customary means the amount that is usually charged to a person without coverage and does not exceed the general level of charges for the specific service in the location where it was performed. Great-West Life determines these amounts by consulting the available Fee Guides of provincial, territorial or national practitioner associations.

Annual deductible

The annual deductible is a specific dollar amount that you must satisfy each calendar year before you receive reimbursement on your first claim. The annual deductible amount is $25 per covered person and $50 for a family.

Co-payment amount

After the annual deductible amount has been satisfied, the Plan will reimburse you for a percentage of the cost of the covered expenses (i.e., 90% for eligible preventive and basic dental supplies and services, and 50% for eligible major dental procedures). The remainder (i.e., 50% for major restorative and 10% for other eligible services) is the amount that you are required to pay toward each eligible expense. This is referred to as the co-payment amount.

Important: The Member is responsible for any portion not reimbursed by the Plan, even in cases where the dental practitioner charges more for a given service or procedure than the amount specified in the applicable Dental Association Fee Guides in effect the previous year.

Maximum reimbursement amount

In any calendar year, the Plan will reimburse an annual maximum amount of $1,700 for each covered person. This excludes orthodontic services, which has a separate lifetime limit (see below).

If your coverage starts in the second half of the year (i.e., on or after July 1st of that year), the maximum amount that the Plan will reimburse for that year will be $850.

Lifetime limit – orthdontic services

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

Treatment plan

Before beginning a treatment or procedure that is expected to cost more than $300, you and/or your dentist should submit an estimate of the proposed work to Great-West Life. Great-West Life will send you a Predetermination of benefits statement to let you know if the work is covered by the Plan and, if so, the amount of the estimated cost that will be paid. In some cases, the treatment you are requesting may not be covered however an alternate treatment may be considered. The Public Service Dental Care Plan (PSDCP) has an Alternate Benefit Clause (ABC) which is a plan provision that allows payment towards an expense that would otherwise not be covered, or limits payment to the cost of a less expensive, reasonable and customary dental service. For example, dental implants are not covered but the Plan may pay an alternate benefit based on the cost of a partial denture or fixed bridge. An ABC is not payable in all cases. For example, if you choose an onlay where a filling would have been considered a viable treatment option, none of the costs are covered.

It is important to read all notes and remarks included on the Predetermination of benefits statement issued by Great-West Life and also to ensure that you have not exceeded the yearly maximum reimbursement amount allowed under the Plan. A pre-treatment plan may indicate that a treatment or service is eligible however; there may be limitations or time restrictions that apply. A Predetermination of Benefits statement is valid for six months provided that you and/or your dependants are still covered under the Plan.

Benefits Reimbursed at 90%

Diagnostic (excluding services related to major prosthodontic)

• Examinations , x-rays, tests and laboratory reports (including diagnostic services related to orthodontic treatment)

Preventive

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

Minor Restorative

• Amalgam, acrylic and composite fillings

Endodontics

• Root canal therapy

Periodontics

• Treatment of gums

Minor Prosthodontic Services (removable dentures):

• Repairs and adjustments, relining and rebasing

Surgery

• Extractions of teeth, other surgical procedures

Adjunctive Services

• Emergency services not otherwise specified, anaesthesia

Benefits Reimbursed at 50%

Major Restorative

• Gold foil restorations, metal and porcelain inlays;
• Onlays; and
• Crowns

Major Prosthodontic Services

• Diagnostic services, complete dentures, partial dentures, fixed bridges (abutments/retainers, pontics), repairs of fixed bridges.

Orthodontic

Submitting your claims

Claims must be submitted to Great-West Life within fifteen (15) months of the date on which the expense was incurred. For orthodontic treatment, claims must be submitted within fifteen (15) months of the date of each monthly visit throughout the treatment period. Claims submitted after that fifteen (15) month period will not be paid unless the member can demonstrate that it was impossible to submit the claim within that time. Further, except in the case of legal incapacity, no claim will be paid if it is submitted more than 24 months after the expense was incurred.

If you have incurred expenses that are eligible for reimbursement, you should complete an authorized claim form with the appropriate information, including:

• your full name and address, including your postal code;
• your plan and certificate number;
• your spouse or common-law partner's plan and certificate number, when applicable,; and
• your signature.

The dentist must also complete his or her section on the claim form. Incomplete forms will be returned to you for completion. Attach your bills or receipts, ensuring they provide full details of the services rendered or purchases made.

Your claims should be sent to the appropriate group benefit payment office as outlined in Appendix D.

Submitting your coordination of benefits claims

If you are a member of the Public Service Dental Care Plan (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 PSDCP membership, claims for your spouse or common-law partners expenses should be submitted to his or her 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 will be determined by the Canadian Life and Health Insurance Association (CLHIA) guidelines for co-ordination of benefits. Under these guidelines, the spouse or common-law partner whose birthday falls earlier in the year must claim the children's expenses first under his or her plan. In case of divorce or separation, the following order of submission must be followed:

• the plan of the parent that has custody of the child;
• the plan of the spouse of the parent that has custody of the child;
• the plan of the parent that does not have custody of the child; and finally
• the plan of the spouse of the parent that does not have custody of the child.

Note: If you and your spouse or common-law partner are both members of the PSDCP, follow the process noted above to determine which plan you should first submit your expenses to. A claim does not need to be submitted to the other plan/certificate number for the unpaid balance of eligible expenses. Indicate the plan and certificate number of your spouse/common-law partner's dental plan on the initial claim form, and Great-West Life will process the eligible claims under both memberships. Payment under your spouse/common law partner's plan and certificate number will be made to your spouse or common-law partner unless he or she authorizes Great-West Life to issue the payment directly to you by completing the "Authorization for Claims Submission and Redirection of Payment form".

Claims payment

Once your claim has been assessed, an Explanation of Benefits will be forwarded to you by the Great-West Life with your benefit payment. Payment will be issued to you or, on signed instructions from you, may be issued to your spouse or common-law partner ("Authorization for Claims Submission and Redirection of Payment form") or to the dentist (claim form (PDF version, 126 KB)) (The Great-West Life Assurance Company). Payments are normally made in a lump sum. However for orthodontic services, you will normally be reimbursed on a monthly basis provided a completed claim form with receipts are forwarded to Great-West Life. The calculations for these payments will be based on the information submitted by the orthodontist on the pre-treatment plan.

You may re-direct payment of claims for your eligible dependants to your spouse or common-law partner using a form called the Public Service Dental Care Plan (PSDCP) Authorization for Claims Submission and Redirection (PDF version, 57 KB).

As the member, you can authorize a spouse or common-law partner to submit dental claims on your behalf when the claims are for your eligible dependants.

In some situations you may not have care and custody of your eligible child(ren). In that case, you may authorize the person who does have care and custody to file claims and receive claims payment for dental services received by your eligible child(ren). Should you subsequently wish to rescind such an authorization, you may do so by writing to Great-West Life.

Appealing an assessment

Occasionally you may disagree with an assessment made by Great-West Life. When an issue cannot be resolved with Great West Life, the matter should be referred to the appropriate Board of Management at the address indicated below. The member, your departmental Compensation services or bargaining agent referring the matter should ensure that all the particulars of the case are provided.

For members represented by Public Service Alliance of Canada (PSAC), details related to your appeal should be addressed to:

Board of Management
Dental Care Plan (PSAC)
140 O’Connor Street
8^th Floor East Tower, #08102
Ottawa, Ontario
K1A 0R5

For members of the Canadian Armed Forces, details related to your appeal should be addressed to:

Canadian Armed Forces Dental Care Plan Board
Director General Compensation and Benefits
Directorate of Pensions and Social Programs
MGen George R. Pearkes Building
101 Colonel By Drive
Ottawa ON K1A 0K2

For all other members, details of the case should be addressed to:

Board of Management
Dental Care Plan (NJC)
P.O. Box 1525, Station B
240 Sparks Street West
7th Floor
Ottawa, Ontario
K1P 5V2

Diagnostic

Preventive

Restorative

Endodontics

• pulp capping
• pulpotomy
• root canal therapy
• periapical services
• other endodontic procedures

Periodontics

• non-surgical services
• surgical services
• post-surgical treatment
• occlusal equilibration
  not exceeding 8 time units per year (12 months)
• scaling and root planing (limited to 6 time units per calendar year)
• other periodontic services

Note: Up to 6 additional units of scaling/root planing can be allowed in cases of documented periodontitis with the pre-approval of a treatment plan.

Note: One (1) time unit means 15 minutes.

Prosthodontics

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

Orthodontic Services

Adjunctive General Services

• emergency services not otherwise specified
• anaesthesia in connection with oral surgery and drug injections
• drug injections
• consultation
• house call, hospital call and special office visit

General

No benefit is payable under the PSDCP for the following dental services and supplies:

1. services and supplies, or any portion thereof, that are covered under any provincial, territorial or other public dental, hospital or health plan under which the person is eligible;
2. services and supplies, or any portion thereof, that 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, that 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 and non-precious metals, if such treatment could have been rendered at a lower cost by means of a reasonable substitute consistent with generally accepted dental practice, except for that portion of expenses that would have been incurred for treatment by means of a reasonable substitute;
7. user fees, co-insurance charges or similar charges that are in excess of charges payable by a government dental, hospital or health plan;
8. dental treatment that is not yet approved by the Canadian Dental Association or that, in the opinion of Great-West Life, is clearly experimental in nature;
9. services and supplies that, in the opinion of Great-West Life, 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 before the date the persons 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 that is not a Class I, II or III malocclusion, except for a child under 19 years of age;
14. charges for a periodontal appliance, occlusal equilibration, and other related service as a result of a temporo-mandibular joint dysfunction (TMJ dysfunction) or vertical dimension correction; and
15. implants and implant-related services.

Specific limitations with respect to major services

1. Services for the installation of prosthodontic appliances (for example, fixed bridges, pontics and abutments, temporary or permanent, partial or complete dentures) 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 that replaces the teeth extracted shall be covered;
      2. the existing fixed bridge is at least five (5) years old and cannot be made serviceable (irrespective of who paid for the existing appliance);
      3. reimbursement of existing denture under the PSDCP was at least 5 years ago;
      4. the existing appliance was temporarily installed; When a temporary prosthodontic appliance is installed as part of major restorative services, plan coverage for permanent prosthodontic appliances will be provided without regard to when the temporary appliances was first installed provided that the person was covered under the Plan when the temporary appliance was installed.
      5. 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
      6. 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. The necessary replacement of fillings (same tooth and surface) will be paid under this plan once every 24 months irrespective of the age of the filling. The necessary replacement of crowns will be paid under this plan once every 60 months irrespective of the age of the crown.
3. The necessary replacement of crowns will be paid under this Plan once every 60 months irrespective of the age of the crown.

For Canadian residents except residents of Quebec:

Health and Dental Claims Centre
P.O. Box 6025, Station Main
Winnipeg MB
Canada
R3C 3C7

Toll free numbers: 1-855-415-4414 (service in English and French)

TTY – For the Deaf or Hard of Hearing: 1-800-990-6654 or Winnipeg (204) 946-7281

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

Toll free number: 1-855-415-4414 (service in English and French)

TTY – For the Deaf or Hard of Hearing: 1-800-990-6654 or Winnipeg (204) 946-7281

For employees residing outside Canada

Great-West Life Health and Dental Benefits
Foreign Benefits Payments
P.O. Box 6000
Winnipeg MB
Canada
R3C 3A5

Toll free numbers: 1-855-415-4414 (service in English and French)

TTY – For the Deaf or Hard of Hearing: 1-800-990-6654 or Winnipeg (204) 946-7281