Morneau - Extend Health and Dental Plans

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  1. Attributes
    • employee: usually active, full-time employee and their dependants
    • dependants: legal/common-law spouse, dependent children ≤ 18 (25 full-time student)
    • cost sharing: through payroll deduction, deductibles and coinsurance
  2. Reasons for upward pressure on drug plan costs 
    • introduction of more expensive drugs
    • shift towards early release from hospital
  3. Reimbursement systems
    • pay as you submit: pay in full and file a claim for reimbursement
    • pay direct: claim is adjudicated for price and eligibility directly between the claims administrator and the pharmacist; only pay deductible or coinsurance
    • hybrid: pay in full, pharmacist electronically files claim
  4. Reasons for rising extended health care costs
    • changing demographics: older people take more prescription drugs; people live longer
    • government cost-shifting: shorter hospital stays shifts costs that would be covered
    • prescription drug costs: average pharmacy fees, quantity, introduction of new drugs
  5. Modifications to drug programs
    • generic substitution: unless prohibited by physician; same active ingredient / strength
    • lower-cost alternatives: based on price of lowest-cost drug
    • therapeutic substitution: less expensive drugs with different active ingredients
    • lifestyle drugs: limited (smoking, sexual dysfunction, anti-obesity, oral contraceptives)
    • drug utilization review: analyze appropriateness of drug usage
    • managed care formularies: covers specific list of eligible drugs, updated regularly
    • three-tier co-payments: amount reimbursed is determined by employee’s choice
  6. Categories of dental services
    • basic services: diagnostic, preventive, restorative
    • supplementary basic services: endodontics, periodontics, some surgical services
    • major services: crowns, removable prosthodontics
    • orthodontics: braces to correct misaligned teeth
  7. Taxation
    • premium paid by employee (if any) is not directly deductible from income, but may be included in the calculation of the individual medical expense tax credit
    • employer contributions = operating expense
    • employer contributions for private health services are not added to income, except QC
Card Set:
Morneau - Extend Health and Dental Plans
2014-04-12 15:27:49
Pension & Benefits
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