Integrating Drug Benefit Plans with Government Programs

In British Columbia, Saskatchewan and Manitoba, plan sponsors may implement integration policies to ensure plan members in these provinces register for their provincial government plans in order to coordinate benefits. It is important to note that residents are not automatically enrolled in the provincial pharmacare program, but must apply for coverage. If these plan members do not apply for the provincial coverage, the potential exists for the employer sponsored group benefit plans to pay for prescription drug expenses that should be paid by the provincial plan.

In these provinces, residents pay for their full prescription costs until they reach a deductible which is based on their combined family income. Once they satisfy the deductible, the pharmacare program begins to assist with eligible drug costs for the balance of the year. Residents can still submit eligible drug expenses to the employer sponsored plan prior to reaching their provincial pharmacare deductible. Even after they qualify for the provincial plan, they can continue to submit any portion of eligible drug expenses not paid by the provincial plan to their employer sponsored plan for reimbursement.

Rather than have all employees residing in these provinces enrol in the provincial plan, some plan sponsors have established a claim threshold, at which point plan members are required to provide proof of enrolment in the provincial plan before additional claims are paid under the employer sponsored plan.

It is important for the plan sponsor to ensure the administrator for the drug benefit has the capability to effectively manage this integration when they are processing drug claims.

Prescription Drug Plan Changes – New Brunswick & PEI

On December 10, 2013, the government of New Brunswick tabled Bill 27, the Prescription and Catastrophic Drug Insurance Act, that is intended to prevent people from experiencing financial hardship due to the cost of prescription drugs. This plan will be fully implemented by April 1, 2015 with insurers having to meet the Plan’s minimum coverage standards from then onwards.

Effective immediately and continuing until March 31, 2015, the Act will prohibit employer sponsored plans from amending or cancelling prescription drug coverage if the primary purpose is to transfer costs to the provincial drug plan. The New Brunswick Prescription Drug Program (NBPDP) formulary will roll out in two phases.

• Phase 1, effective May 1, 2014
  Enrolment will be voluntary and contribution based on the resident’s ability to pay. Residents who are members of an employer sponsored drug benefit will be eligible if they meet one of the following criteria:
• They’ve reached their annual or lifetime maximum, or
• They need a specific drug not covered by the employer sponsored drug plan

The NBPDP will have a 30% co-payment with a $30.00 maximum per prescription.

• Phase 2, effective April 1, 2015
  Coverage becomes mandatory and every resident must be enrolled either in NBPDP or an employer sponsored plan compliant with NBPDP minimum coverage standards.

On October 1, 2013, the Prince Edward Island’s Catastrophic Cost Drug Program came into effect. The employer sponsored plan is always the first payor and this program is not expected to have any impact on employer sponsored drug benefit plans.

Required Postings for Employers

Statutory and regulatory requirements demand employers post the following:

• A copy of the Occupational Health and Safety Act
• Your health and safety policy
• Your pay equity plan
• Your workplace harassment and violence prevention policies
• Where applicable, signs about smoking areas in the workplace

Provincial Dental Fee Increases for 2014

With the exception of Alberta, each jurisdiction in Canada posts their Dental Fee increases by procedure. In Alberta, insurers establish their own reimbursement levels for Dental services which can result in discrepancies when a change is made to a new insurer.

The actual adjustment does vary by procedure code but a summary of overall increases by province and the effective date of the change follows:

• British Columbia 1.8% effective February 1
• Alberta 3.99% (based on a two year average) effective February 1
• Saskatchewan 2.7% effective January 1
• Manitoba 3.1% effective January 1
• Ontario 2.01% effective January 1
• Quebec 2.0% effective January 1
• New Brunswick 3.0% effective January 1
• Nova Scotia to be effective February 1 but not available
• Prince Edward Island 2.04% effective January 1
• Newfoundland & Labrador 2.5% effective January 1
• Northwest Territories 2.0% effective April 1
• Nunavut 2.0% effective April 1
• Yukon to be effective April 1 but not available

These are overall averages and adjustments by procedure could be higher in some cases, for example, in Ontario there is an increase of 4.21% for Diagnostic treatments and 16.23% for a tooth restoration if an amalgam is used but the increase for preventive treatment is only 0.11%. Therefore, the impact of these fee increases is directly dependent on the claim utilization patterns of the group.