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What is coordination of benefits?

Key takeaways.

When someone is covered by more than one benefits plan, the plans work together to pay any claims.

  • There are several scenarios to determine which plan pays first.
  • The reimbursement under both plans won’t be more than 100% of the original claim amount.

What does coordination of benefits mean?

How does coordination of benefits work.

There are 3 main scenarios where coordination of benefits comes into effect. In each case, one plan pays first (the primary payor) and one plan pays second (the secondary payor).  

  • Scenario 1: You're covered under your employer’s benefits plan and as a dependant under your partner’s plan
  • Scenario 2: Your partner is covered under their employer’s benefits plan and as a dependant under your plan
  • Scenario 3: Your dependant kid(s) has coverage under both you and your partner’s benefits plans

How do you determine which plan pays first?

Look for your scenario below and then submit your claims in the order shown. Send your claim to the first plan on the list. After your claim has been processed, if there are any unpaid amounts, submit a claim to the next plan on the list. Work your way down the list 1 by 1 as applicable.

I’m married (or living common-law) and we each have a workplace benefits plan

  • Your own benefits plan.
  • Your spouse’s plan. 

Likewise, your spouse’s claims should be submitted to their own plan first.

I’m married (or living common-law) and we’re submitting a claim for our child

  • Plan of the parent whose birthday (month and day) falls earlier in the calendar year (ignore the year of birth and just look at month and day).
  • Other parent’s plan.

I have joint custody of my children. My ex and I are each remarried or living common-law.

  • Plan of parent whose birthday come first in the calendar year (ignore the year of birth and just look at month and day).
  • Plan of the second parent.
  • Plan of the spouse of the parent whose birthday comes first.
  • Plan of the spouse of the second parent.

I have sole custody of my children. My ex and I are each remarried or living common-law.

  • Plan of the parent with sole custody.
  • Plan of the spouse of the parent with sole custody.

I’m a full-time university student with coverage through my university and through my job, but am also considered a dependant under my parent’s plan. 

  • Your student or work plan, whichever one you got coverage with first.
  • Your student or work plan, whichever one you got coverage with second.
  • Your parent’s plan. 

Exception: If the student is a Quebec resident, and is submitting a drug claim, submit to the student plan last.

I have 2 jobs and have coverage with both

  • Plan of the full-time job.
  • Plan of the part-time job. 

Note: If you work the same hours at both jobs or have 2 part-time jobs, submit to the plan of the job where you started working first.

I have a retiree plan and a plan at my new job

  • Plan of your new job.
  • Retiree plan.

How are coordination of benefits claims reimbursed?

Submit your claim to your benefits plan first, for payment according to your coverage. 

Once you receive an explanation or statement of benefits for that claim, you can submit a claim for the remaining amount to the second plan and it will be paid according to the coverage of that plan. 

The reimbursement under both plans won’t be more than 100% of the original claim amount. 

What's next?

Now that you understand more about coordination of benefits, you may want to:

  • Check your coverage or make a claim using your online account Opens a new website in a new window if your benefits are through Canada Life.

Use your online account to submit a claim, manage your plan and explore additional coverage options. 

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Coordination of Benefits: Can I Have More Than One Benefit Plan?

By: Benefits by Design | Tuesday July 28, 2020

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It is common for employees to be covered by more than one group insurance plan. This is typically achieved through a spouse or common-law partner’s plan.

When an individual is covered by more than one plan, coordination of benefits becomes a requirement to ensure everything runs smoothly between the two plans.

Employee Marital Status Options and How it Relates to Health and Dental Benefits

What is Benefits Coordination?

Having two plans often results in overlapping coverage. As a result, the question of which Insurer pays first (known as the first payor) crops up. Extended Health Care (EHC) and Dental Insurance are among the most common coverages that overlap. The coordination of benefits offers a clear framework between the two insurance companies. It indicates who is responsible for paying a claim and in which order.

Benefits Coordination in Action

If Insurer A is the first payor and covers 80% of the claim, Insurer B could cover the other 20%, resulting in full coverage.

How Do I Set Up Benefits Coordination?

When you enroll in a group insurance plan, there will be a section on the enrollment form asking if you have comparable coverage under another plan.

If this is your first and only group benefits plan , this section will not apply. However, if you have existing coverage, you’ll need to carefully consider how you want the two plans to work together, if at all. 

In which case, you can choose to either waive coverage or coordinate the benefits.

Employee Benefits Participation Requirements Explained

Waiving Coverage

When you choose to waive coverage , you are indicating that you do not wish to be covered under a benefits plan because you have comparable coverage. 

You may choose to waive coverage for yourself and your dependents, or your dependents only. By waiving coverage, you will not pay the premiums for those benefits, but you will be relying only on one insurance plan for coverage.

It is important to note that  you must have comparable coverage under another plan  to waive a benefit. 

Watch the Nomad tutorial on waiving and unwaiving benefits

Coordinating Benefits

When you choose to coordinate benefits, you indicate a desire to be covered by both plans. Like waiving coverage, you can choose to coordinate benefits for yourself and your dependents, or yourself only.

Coordinating your benefits is like having a back-up plan to cover additional expenses not covered by the first plan. This does mean, however, that applicable premiums will be deducted from your pay for both plans.

Benefits Coordination Examples: Who Pays First?

Let’s take a look at a few common examples to see benefits coordination in action.

Who Pays First: My Plan or My Spouse’s Plan?

If you are covered as a member under a plan, that plan will  always  pay before a plan that covers you as a dependent. You must submit the claim to your own plan first before utilizing dependent coverage.

Who Pays First: My Plan or… My Other Plan?

If you have the  same status  under more than one plan (i.e. two group benefits plans), the plan that has covered you the longest pays first.

Who Pays First: My Plan or My Kids’ Plan?

Children often gain some form of health or dental coverage through their post-secondary institution or part-time job. These plans will  always  pay before any plan where a child is covered as a dependent.

Who Pays First: Dependent Children

If both parents have plans and their children are covered as dependents under each, the plan of the  parent with the earlier birth date  in the calendar year pays first. Unless that dependent child has a plan of their own through a post-secondary institution or part-time job (see above).

What if I Leave my Job or Lose Coverage?

If you leave your job and thereby lose your coverage, you should inform your other Insurer of the change as soon as possible, but certainly within 31 days. 

If you inform them within this window, you should be able to re-enroll and restore full coverage without issue. Otherwise, you may be considered a late applicant and be required to submit medical evidence, which can affect your coverage.

Coordination of benefits is just one aspect of group insurance, but there’s a lot more to know.

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  • Coordination of Benefits
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Did You Know?

Coordination of Benefits is a provision that determines the sequencing of coverage when Plan members and their dependents are eligible for benefits under more than one private health care plan. The PSHCP uses the benefit coordination guidelines established by the Canadian Life and Health Insurance Association (CLHIA). The specific sequencing for coordination of benefits under the PSHCP is outlined in the Member Booklet (coming soon) and the Plan Document .

Coordination of Benefits allows two people with PSHCP coverage who are married or in a common-law relationship to be covered as dependants by each other’s plans. Eligible expenses can be submitted under both members’ certificate numbers, providing greater reimbursement (up to 100%) to the family.

PSHCP members can also coordinate their benefits with other private plans.

To inform Canada Life that you would like to coordinate your benefits, you must complete Positive Enrolment. During this process, you will be asked to provide your spouse’s PSHCP certificate number and plan number, or information about other private group health care plans under which you or your dependants are covered. Such information includes the type of coverage offered (e.g. drugs, health care, other), whether it is for single or family coverage, and by what relationship you or your dependant is eligible for such coverage (e.g. your child is covered through your spouse’s plan). You can review and update your coordination of benefits information in your account through the PSHCP Member Services website at canadalife.com/pshcp .

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Submit a claim to more than one plan

Also called coordination of benefits or COB

Covered by more than one benefit plan? You can send the same claim to all the plans. You could get back the full amount you claim.

Keep copies of your statement and receipts – including drug receipts. Each plan will tell you what you need to send with your claim . Also, if you need a copy of your claim statement in future, they’re available online, after you sign in to your plan on the website . Once signed in, your Claims history presents itself on the screen. Click on  the “Statement” icon (on the right beside a specific claim) to find the statement for that claim.

Under some plans, you don't have to use your benefits first . You can use your  health care spending account , wellness account, taxable spending account, or lifestyle account first. Then you can have your benefits pay any unpaid balance. Check your benefits guide to see if your plan offers that choice.

Who is the claim for?

  • First send the claim to your plan.
  • Then send the claim to your spouse's plan (if your plan didn't pay the full amount).
  • Send the claim back to your plan if there's still an unpaid amount and you want to see if your health care spending account (HCSA) can help pay for it. (You may also be able to use your wellness account, taxable spending account, or lifestyle account.)
  • Then you can send it to your spouse's HCSA or other account.

Not all plans offer health care spending, wellness accounts, taxable spending, or lifestyle accounts. If not, you can skip that step.

Retired or have another job?

  • If you have two full-time jobs Send the claim to the job you started first. Then send it to your other plan. Then to your spouse's plan.
  • If you have a full-time and a part-time job Send the claim to your full-time job's plan first. Then to your part-time job's plan. Then to your spouse's plan.
  • If you're retired with a full- or part-time job Send the claim to your full-time job's plan first. Then to your part-time job's plan. Then to your retiree plan. And then to your spouse's plan.

For your spouse

Your spouse can be someone you're legally married to, or living with in a common-law relationship. Or someone who meets your plan's definition of spouse.

  • First your spouse needs to send their claim to their plan.
  • Then you can send the claim to your plan (if their plan didn't pay the full amount).
  • If there's still an unpaid amount, a health care spending account (HCSA) may help pay for it. Send the claim back to your spouse's plan. (You may also be able to use a wellness account, taxable spending account, or lifestyle account.)
  • Then you can send it to your HCSA or other account.

For your child

  • First send the claim to the plan of the parent with the birthday that comes first in the year.
  • Then send it to the other parent's plan (if the first plan didn't pay the full amount).
  • If there's still an unpaid amount, a health care spending account (HCSA) may help pay for it. Send the claim back to the first plan's HCSA. (You may also be able to use a wellness account, taxable spending account, or lifestyle account.)
  • Then send it to the second plan's HCSA or other account.

(Shared custody – separation, divorce, re-marriage, living in a new common-law relationship)

  • First send the claim to the plan of the parent whose birthday is first in the year.
  • Then send it to the plan of the parent with the birthday that's second.
  • Then send it to the plan of the spouse of the parent whose birthday was first.
  • Then send it to the plan of the spouse of the parent whose birthday was second.
  • If there's still an unpaid amount, you may be able to claim it under a health care spending or other account. (You may also be able to use a wellness account, taxable spending account, or lifestyle account.) Send the claim to the HCSA or other account, in the same order as above.
  • First send the claim to your child's college or university benefits plan.
  • Then send the claim to any other plans. (Use the same order as above.)
  • For drugs covered under Quebec's public drug plan (RAMQ) – First send the claim to your child's other plan(s). (Use the same order as above.)
  • Then send the drug claim to the college or university plan.
  • For non-drug claims – Use the same order shown above under College/university students.

Which plan pays your child's claim first?

Is your birthday closer to January 1 st than your spouse's birthday? If it is, your plan pays first. If not, your spouse's plan pays first.

Same birthday?

If both parents have the same birthday, use the first initial of your first names. Whichever initial comes first in the alphabet is the parent whose plan pays first. Example: If your name starts with 'A' and the other parent's first name starts with 'S', send claims to your plan first.

Job change?

If you or your spouse recently changed jobs, it may be time to update your benefits.

Your plan administrator can answer questions about your specific group benefits plan. Your benefits booklet, available after you sign in to the Plan Member Secure Site (under the ‘My benefits’ tab), also contains information about eligibility, coverages, and more.

Need to submit a claim?

Submit your benefits claims online or with the app. Get started now.

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How To Coordinate Your Personal and Group Health Benefit Claims

Written by Gavin Prout

If you have individual health insurance and are covered by a group plan, figuring out how to submit a claim to maximize your health benefits can be confusing. Understanding how to co-ordinate the plans is important. Luckily, the Canadian Life and Health Insurance Association (CLHIA) created guidelines for insurance companies that set out who pays when, and how much. The guidelines ensure that regardless of which insurer you are with, how your benefits are coordinated is handled the same way.

Follow these steps to coordinate your personal and group health and dental benefit claims.

Step 1: Determine if You Have Group Health Insurance Benefits

An insurance policy that provides coverage for many people under one contract is called “group insurance.” The group is typically made up of employees of the same company or members of the same is organization (e.g., a union or trade association) who have a relationship beyond the desire for insurance. Each individual covered under the ‘group’ is called a Plan Member.

Your group insurance will be provided by your employer or your spouse’s employer, or you may have ‘association’ group health benefits through your affiliations. 

The money you receive based on a claim is called your Group Benefits. They are also known as Employee Benefits. A claim can be submitted on behalf of either a plan member or a dependent of the plan member.

Step 2: Determine if you have personal health insurance benefits

Personal insurance is an insurance policy that provides coverage for an individual and their dependents. You have this type of plan if you have purchased and paid for the policy personally and it is issued and owned in your name. Personal Insurance is also known as Individual Insurance.

Step 3: Who do you submit a claim to first?

medical-and-health-insurance-claim-form-with-stethoscope-on-clipboard

Coordination of benefits determines which insurance plan pays first and how much each insurance plan pays. If you have both individual and group health or dental coverage, the Group Plan will typically pay first.

The Coordination of Benefits Provision limits the total benefit amount you can claim, up to a combined maximum of 100 percent of the cost of the eligible expenses incurred. This means that any overlapping coverage you have on a specific claim will not result in you receiving total payments greater than the actual cost of the claim you submitted.

Your group insurer (who is typically ‘first payer’) will first determine the amount of the expense you incurred that is eligible under the plan, and pay the claim as though you have no other coverage.

So the first step is to submit your claim to your group insurer and keep copies of all original receipts.

Step 4: Submit any unpaid portion to the ‘second payer’

The second payer is typically your personal insurance company. When you submit your claim to your individual insurer, be certain to attach all copies of your original receipts along with the explanation of benefits (EOB) you received with your payment from the group plan. The EOB summarizes the charges submitted, the dollar amount allowed by the insurer for each service, the amount paid, and the balance owing  by you (the Insured) if any. If any services were not paid, reasons are given for the benefit reduction or denial of coverage.

This “second payer” insurer will calculate the amount of the eligible expenses it must pay, which is the lesser of

  • The amount the insurer would have paid had it been first payer
  • One hundred (100) percent of the eligible expenses reduced by the benefit amount paid by the first payer.

The combined payment from both (or all) plans cannot exceed 100% of the eligible medical or dental expenses. Sometimes the combined payment may be less than what you had to pay out of pocket.

Step 5: Dealing with plan maximums

Your two plans are almost always going to have different types of coverage, maximum visits per year, and deductibles. Some health insurance plans­ limit the number of visits per year to a health or dental practitioner – for example once every 9 months – and some plans have an annual dollar maximum. 

It is important to understand that when a plan (first or second payer) pays out any benefit for a visit, it will count as a visit towards the maximum under both plans.

If your dental claim is because of an accident, your health insurance plan with accidental dental coverage will be the first payer.

Step 6: Special Rules

rules-businessman-with-binder

There are a few special circumstances where the rules for submitting a claim to your first or second payer do not apply:

  • Auto insurance Provincial legislation determines if coverage available under automobile insurance is first or second payer, or whether it will be coordinated with your health and dental insurance.

Out-of-Country/Province Health Care Expenses Other rules have been developed to coordinate benefits when more than one plan covers these emergencies.

  • Workers Compensation This comes into effect if you are making a claim regarding a work-related injury or accident.

In Summary: Why it’s Great to Co-ordinate Benefits

If you have group benefits but don’t have personal health insurance already, it makes sense to carefully review your group plan. Is it meeting your needs and your family’s needs?

Personal health insurance coverage can serve as a financial cushion if

  • you would like additional or even 100% drug coverage or an “emergency back-up fund” for when prescription drug costs get out of hand because of a chronic issue
  • you’re concerned about high healthcare costs that may result from an accident or illness medical crisis and want a “safety net” in place
  • your work is in transition, you are thinking of becoming self-employed or retiring – having your own personal insurance in place ensures you won’t have “gaps” between those times you have group insurance and those times that you don’t.

Talk to us today

If you ever have any questions about managing your health insurance claim, our team is available to help. And if it’s time for you to put your personal health insurance plan in place, we can give you guidance and support on finding the perfect plan to meet your needs and budget.

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Please explain this. What do I do when I get 2 cheques both paying 100% of my medical out-of-country expenses. I was very clear to give full coordination of benefits information to both my work policy and my private policy.

Thank you for your question. My suggestion is that you advise both insurance companies about the mistake. Individuals should never profit off of a travel claim. Coordination of benefits is that both insurance companies speak to each other about the claim and work together to make sure it is paid in full. On the application there is an area to indicate that you have other travel insurance, if they have overlooked that then that may be the issue. Thank you for your question

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Whether it’s travel insurance, individual health and dental insurance plans, or any of the other products in their portfolio, I know that I can vest my trust and confidence in SBIS, because our clients will be well served and protected. SBIS has been and continues to be, a great partner to work with.

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How-to Guide for Coordinating Benefits

UBC faculty and staff who are enrolled in more than one extended health or dental plan have the option of coordinating coverage between their multiple plans (also known as coordination of benefits or COB).

This means that if you submit an eligible claim to the first plan and there’s a portion that was not paid or only partially reimbursed, you can submit that portion to the second plan where it may be considered for reimbursement up to 100% of the allowable amount that can be paid to that claim.

Order matters when coordinating your claims

If the claim is for yourself:

  • You will need to submit it through your plan first, and then any other plan coverage you have.

If the claim is for your spouse or partner:

  • First, they will need to submit it through any coverage they are the plan member for, and then your plan coverage.

For dependent children:

  • The claim will need to be submitted through the plan of whichever parent’s birth month is first in the calendar year, and then through the other parent’s plan second (i.e. if one parent was born in March and the other in November, the claim is submitted through the March-born parent’s plan first, and then through the November-born parent’s plan).

How to set up a COB with Sun Life

If you and your spouse or partner are both UBC employees or if your other plan is also with Sun Life, here’s how to set up a coordination of benefits through the  Sun Life Plan Members’ website :

1. Click on “Submit a Claim”.

2. Click on “My Claims” under the Claims tab.

3. Click on “Coordination of Benefits” and answer the questions as indicated.

Your spouse or partner must also set-up their Sun Life account to allow for coordination of benefits before COB claims may be submitted.  Any extended health and/or dental claims submitted through your spouse or partner’s plan for yourself will be reimbursed directly to your spouse or partner as any reimbursement is paid to the person who is the plan member.

Note: You cannot coordinate claims through the  Sun Life Mobile app  at this time.

If your insurance coverage is not with Sun Life

As a UBC employee, if your other coverage is with an insurance plan that is not Sun Life, here’s how to set up a coordination of benefits through the  Sun Life Plan Members’ website :

  • You will need to confirm with your other insurance plan that they allow for coordination of benefits.
  • If your other coverage does not allow for COB, you will only be able to submit claims through your Sun Life plan for reimbursement.
  • If your other coverage allows for COB, follow the same steps above to set up coordination through your Sun Life account.
  • You will need to contact your other insurance plan to determine how to set up COB for your coverage through their plan.
  • Once you receive reimbursement from Sun Life and their Explanation of Benefits (EOB), you can then submit any remaining balance through your other coverage, along with the EOB for further reimbursement.

Need help setting up your coordination of benefits?

For additional assistance when it comes to setting up COBs for extended health and dental claims, call Sun Life at 1-800-361-3612. Remember to provide the UBC group number (025205) and your member ID (7-digit UBC employee number).

For more information about coordination of benefits, check out the following resources:

  • To set-up or end  coordination of benefits under UBC’s extended health and dental plans
  • Canadian Life and Health Association guide  to coordinating benefits

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Coordination of benefits

What is coordination of benefits (cob).

If you and your dependents are covered for extended healthcare and/or dental benefits under more than one plan, your reimbursement will be coordinated following insurance industry standards. The maximum amount that you can receive from all plans for eligible expenses is 100% of actual expenses. 

The plan that does not contain a COB clause is always considered to be the first payor and therefore pays benefits before a plan which includes a coordination of benefits clause. 

For dental accidents, extended healthcare benefits with dental accident coverage provide reimbursement before dental benefits. 

Where both plans contain a COB clause, claims must be submitted in the order described below. 

How does coordination of benefits work?

Claims for you and your spouse should be submitted in the following order: 

  • The plan where the person is covered as an active full-time employee.
  • The plan where the person is covered as an active part-time employee. 
  • The plan where the person is covered as a retiree.
  • The plan where the person is covered as a dependent (for example, if you are covered as a dependent under your spouse's plan).

Claims for a dependent child should be submitted in the following order: 

  • The plan where the child is covered as an employee. 
  • The plan where the child is covered under a student health or dental plan provided through an educational institution.
  • The plan of the parent with the earlier birthdate (month and day) in the calendar year. For example, if your birthday is May 1 and your spouse's birthday is June 5, you must claim under your plan first.
  • The plan of the parent whose first name begins with the earlier letter in the alphabet if the parents have the same birthdate. 

The above order applies in all situations except when parents are separated/ divorced and there is no joint custody of the child, in which case the following order applies:

  • the plan where the child is covered as an employee.
  • the plan where the child is covered under a student health or dental plan provided through an educational institution.
  • the plan of the parent with custody of the child.
  • the plan of the spouse of the parent with custody of the child.
  • the plan of the parent not having custody of the child.
  • the plan of the spouse of the parent not having custody of the child.

Expenses not covered by the first benefit may be eligible for some reimbursement under the other benefit.

Coordination of benefits information is gathered at the time of each claim submission. When submitting each claim with GreenShield, members will be asked if they have any other group insurance coverage. After the first benefit payor has processed your claim, members will receive an explanation or statement of benefits for that claim. Members can submit a claim for the remaining amount to their secondary plan and it will be paid according to the coverage of that plan. If you and your spouse are both with GreenShield, you only need to submit one claim form and GreenShield will coordinate your benefits for you. 

How does coordination of benefits work when both spouses work for the University and have benefits coverage?

When submitting claims online, please ensure that you and your spouse have both registered for GSC Everywhere, and have accepted the online agreement. This is required for automatic coordination of benefits to occur.  (Watch a video on how to complete registration.)

Whoever incurs the claim must sign in to their GSC Everywhere account and submit the entire expense as the first step.  You will then be asked if there is secondary coverage and if secondary coverage is with GreenShield.  You will be prompted to provide your spouse’s GreenShield Benefits ID number (See example below)

For dependent children, the plan of the parent whose birthdate (month and day) occurs earliest in the calendar year, claims must be submitted under this plan. As like above, the member will be prompted if other coverage and if GreenShield, they will indicate spouse’s GreenShield Benefit ID Number.

  • Michael’s GreenShield Benefits ID number is WTL123456. 
  • Jessica’s GreenShield Benefits ID number is WTL456789.
  • Michael’s Dependent GreenShield Benefits ID number under Jessica’s coverage is WTL456789-01
  • Jessica’s Dependent GreenShield Benefits ID number under Michael’s coverage is WTL123456-01

Michael is submitting a benefits claim for massage in the amount of $100 using his GreenShield benefit ID number WTL123456. During the claim process, it indicates that he has a second payor for benefits coverage through WTL456789 (Jessica's Benefits ID number). This COB will enable GreenShield to automatically adjudicate the claim under both plans without having to submit the balance separately under Jessica’s plan.

Please ensure that you and your spouse have both registered for GSC Everywhere and have accepted the online agreement.

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Please remember to use capital letters / upper case for the “WTL” in your GreenShield member ID number. If you use a lower case “wtl”, GreenShield’s claims system will not recognize your member ID number accurately.

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Effective July 1, 2023, prescription drugs under the Public Service Health Care Plan (PSHCP) are subject to mandatory generic substitution. This means that if you are taking a brand name drug, the PSHCP will only provide coverage at 80% of the lowest-cost generic drug equivalent, when a generic drug equivalent is available. Generic drugs are approved by Health Canada and are pharmaceutically equivalent to the brand name drug as they contain identical medicinal ingredients.If you were taking a brand name drug before July 1, 2023, the PSHCP will provide a legacy period ending December 31, 2023. During the legacy period, prescribed brand name drugs will still be reimbursed at 80% of their cost for those with existing prescriptions.

You can continue taking a brand name drug, however, you will need to pay the difference between 80% of the lowest-cost generic and the brand name drug out-of-pocket.

Exceptions will be granted based on medical necessity. To request an exception for your brand name drug, ask your doctor or nurse practitioner to complete a PSHCP Request for Brand name drug coverage form, available on the Your forms page on the PSHCP Member Services website. 

Any fees that your doctor or nurse practitioner may charge for providing this information will not be reimbursed. 

Submit the completed form to Canada Life at the mailing address, email address or fax number on the form. Please allow us 7 to 10 business days to complete a review of the medical information provided. Canada Life will send a letter outlining the decision.

You can decide to take the brand name drug under the Public Service Health Care Plan (PSHCP) even if you are not approved for an exception, but you will be responsible for the difference in cost between the brand name drug and its lowest-cost generic drug equivalent. This means you will have a higher out-of-pocket expense.

For example, a brand name drug costs $100 and the generic drug equivalent costs $80. If you purchase the generic drug, the PSHCP will cover 80% of the $80 charge, which is $64. Your out-of-pocket amount is $16. If you choose to purchase the brand name drug, the PSHCP will still cover $64, but your out-of-pocket amount will be $36.

If your prescribed brand name drug does not have a generic drug equivalent available, then the Public Service Health Care Plan (PSHCP) will continue to reimburse you for the brand name drug at 80% of its cost. No action is required from you or your doctor or nurse practitioner.

You can find more details about the improvements and changes to the Public Service Health Care Plan (PSHCP) here:

  • Improvements and changes to the Public Service Health Care Plan - Canada.ca Opens a new website in a new window
  • PSHCP Bulletin 45 – PSHCP AA Opens a new website in a new window

Please check with your pharmacy if there are other generics available.

Pharmacies are responsible for checking all available suppliers for stock or obtaining another generic interchangeable product if one is available. 

If all generic versions of a brand name drug are not available due to shortage or backorder, the Public Service Health Care Plan (PSHCP) will reimburse the brand name drug at 80%. This occurs automatically during a shortage, so you do not need to make a special request to Canada Life.  

Once a generic drug is available, reimbursement will be limited to the cost of the generic version.

We continue to receive higher than expected call volumes.

Here are a few examples of how we are working to make this right:

  •  We have increased the number of PSHCP Member Contact Centre agents to serve you better.
  • Our goal is to be able to achieve an average wait time of between 5 to 10 minutes by December 
  • We have extended our hours of operations to temporarily open 7 days a week from November 1 through December 17, 2023. Monday to Friday from 8 am to 5 pm, your local time or Saturday and Sunday between 9 am to 5 pm ET.
  • Note: Towards the end of each business day, we may, if necessary, not let further calls in to avoid disappointment of a wait time exceeding our business hours of operation. Rest assured, you will be advised on the call if this becomes the case.

Before you call, we invite you to check back again here, on the PSHCP Member Services website, for answers to your questions, as updates are being made regularly.   

No – please do not resubmit your claim.

If a claim is submitted more than once, it creates an extra step on our side to match and cancel out one of the claims, slowing down the process and reimbursements.

 Most claims submitted electronically are automatically processed within 2 business days. Claims that require manual review by a claim’s examiner, such as those submitted by paper, may take longer. We apologize for the inconvenience this may cause. 

Submitted claims can be viewed through your PSHCP Member Services account on My Canada Life at Work . Your account provides status updates for all claims. The only exception is if you have visited a provider that needs to have their credentials reviewed. Please do not submit claims for the same service more than once.

If you believe the information you have received about your claim through your Explanation of Benefits statement from Canada Life is inaccurate, please refer to the Plan Directive as a first point of reference. There have been a number of improvements and changes implemented effective July 1, 2023, following negotiations with the PSHCP Partners Committee, comprised of Employer, Bargaining Agents and pensioner representatives, that may mean some claims may be paid differently than before. The following links provide more information:

  • Update: Improvements and changes to the Public Service Health Care Plan - Canada.ca
  • PSHCP Bulletin 43 - PSHCP-AA

Sometimes Canada Life will require additional information from you to process your claim according to the terms of the PSHCP.  To avoid further delays in claim adjudication, please check to ensure all information required has been included in your claim submission and is accurate. If sending in a paper claim form, please ensure that you have signed this ahead of mailing. We will contact you when this is required and will reassess your claim once all additional information is provided. 

Where Canada Life is both the primary insurer under the PSHCP, and Canada Life is also the secondary insurer (spouse/common-law partner is also a PSHCP participant OR the spouse/common-law partner’s employer has Canada Life coverage) only one claim needs to be submitted under the primary plan . If the coordination of benefits information is provided with the claim, the secondary plan adjudication will happen automatically without the need for another submission.  

If Canada Life is not the secondary plan provider, submit your primary plan claim to Canada Life, and use our Explanation of Benefits Statement to submit your secondary claim to your secondary provider.

Finally, if the PSHCP is the secondary plan to your spouse/common-law partner, and their coverage is with another carrier, please submit to the spouse/common-law partner’s plan first and then to the PSHCP.

To submit an electronic claim under the Public Service Health Care Plan (PSHCP) to Canada Life, you must first register for a PSHCP Member Services account through My Canada Life at Work TM . 

Submitting a claim online is the easiest and fastest way to get a claim processed and reimbursed. To make a claim, please sign in to your account through My Canada Life at Work TM and follow these instructions:

  •  Sign in through My Canada Life at Work TM
  • Go to Submit a claim .
  • Choose the appropriate claim type and follow the steps to complete the transaction.

Other web features:

  • Coordination of benefits: You may submit coordination of benefit claims between 2 Canada Life plans or submit the remaining balance of a claim already processed by another benefit plan.
  • Positive enrolment: You may complete or update your positive enrolment information, including direct deposit information.
  • Drug look-up: You can use this search feature to look up drug information by entering a drug name, or drug identification number (DIN). This includes whether or not a drug requires prior authorization. 
  • File submission: You must submit copies of receipts for all medical expenses. You can do so by submitting photos or electronic files. You can also provide electronically any supporting documentation requested by Canada Life, such as physician referrals and medical questionnaires.

Where possible, Canada Life adopted the Reasonable and Customary Charges you were previously accustomed to.

However, there may be some instances where the Reasonable and Customary Charges could be different as these are aligned with industry standards. Just as Reasonable and Customary Charges will be assessed from time to time by Canada Life and adjusted as needed, some changes should be expected from the prior administrator.

In some cases, Canada Life has higher values. If you come across a Reasonable and Customary Charge that looks lower than what you were charged, please call the PSHCP Member Contact Centre at 1-855-415-4414, Monday to Friday from 8 am to 5 pm, your local time, Saturday to Sunday between 9 am to 5pm ET., with your expense details.

Canada Life has moved aggressively to hire and recruit new agents for the PSHCP Member Contact Centre. 

The process of onboarding and training new call centre agents is lengthy for three reasons:

  •  We are handling sensitive health and medical information, and agents must obtain security clearances as required by the Government of Canada.
  • We are committed to providing rigorous training for insurance benefits, which is more complicated than most call centre agent roles. 
  • There is a tight labour market pool for call centre agents.

Wherever possible, we have streamlined our processes to get more agents on the phones, faster. 

The PSHCP Partners Committee, comprised of Employer, Bargaining Agents and pensioner representatives negotiated benefit improvements and changes to the PSHCP. These came into effect July 1, 2023 . 

The following links provide more information:

Changes to the PSHCP are not decided by Canada Life and are unrelated to the change in plan administrator. Canada Life administers your coverage based on the Plan Directive.

If your claim says pending, then it is in progress.  If your claim is within those handling times, we ask that you check back later to see if the status has changed to “paid”. 

If additional information is required for a manual claims assessment, we will contact you directly and reassess your claim once that information is received.

We apologize for any challenges you may have experienced in accessing your PSHCP Member Services account through the My Canada Life at Work™.

If you do experience an error message, please refresh your browser, and attempt to log in again. Most errors are solved by exiting the session, clearing all caches in the browser and trying again.  

If the same message appears, please take a screen shot for future reference and call the PSHCP Member Contact Centre at 1-855-415-4414, Monday to Friday from 8 am to 5 pm, your local time, Saturday to Sunday between 9 am to 5 pm ET until December 17, 2023.  

If a prescription drug, product or medical service that was covered for you previously is declined, first check the Plan Directive to confirm if there have been plan coverage changes. 

If your claim is for an urgent, life-sustaining item, beginning November 6, 2023, we are introducing an urgent escalation process to have your previously filed claim assessed on a prioritized basis. 

The appeals process is available to all PSHCP members who do not agree with a decision regarding their claim, benefit entitlement or coverage (for example, level of coverage, waiting period, refund of contributions) and wish to have their file reviewed. However, prior to submitting an appeal, you should first attempt to resolve the issue with us if your appeal is claim-related, or with your departmental compensation office or Pension Centre if your appeal is coverage-related.

If you’re still not satisfied with the decision from Canada Life after it has been reviewed, you can submit an appeal to the Federal PSHCP Administration Authority.

Members wishing to submit an appeal to the Federal PSHCP Administration Authority may send a written submission to:

Federal PSHCP Administration Authority PO Box 2245 Station “D” Ottawa ON K1P 5W4

For more information on the appeals process, visit:  https://pshcp.ca/appeals/how-to-submit-an-appeal/

We recognize that some claims require immediate attention. That’s why as of November 6, 2023 , we’re expanding our processes to ensure urgent claims are quickly identified and prioritized by our teams.

Please use this process if your claim is for urgent, life-sustaining prescription drugs, services or treatments including, but not limited to:

  • Mechanical ventilation
  • Renal dialysis or Insulin 
  • Cancer drugs
  • Artificial nutrition and hydration supplies like feeding tubes

This process is only for claims already submitted. 

If your claim does not fall into these urgent categories, it will not be expedited. This is to ensure we can triage the most urgent claims on a priority basis.  

The Day Supply Limit for prescription drugs under the Public Service Health Care Plan (PSHCP) is 100 days for both acute and maintenance drugs. 

If you are travelling for an extended period, you can request an increase to your Day Supply Limit for up to 200 days from your pharmacist. You do not need to call Canada Life for approval. 

Two weeks before you travel, ask your pharmacist to submit your request for additional day supply. Your pharmacist will need your PSHCP benefit card to submit your request and the applicable dates. 

If your pharmacy is unable to process the request, please call the PSHCP Member Contact Centre at 1-855-415-4414, Monday to Friday from 8 am to 5 pm, your local time, Saturday to Sunday between 9 am to 5 pm ET until December 17, 2023.  

The Government of Canada, along with the PSHCP Partners Committee, comprised of bargaining agents, the employer and pensioner representatives have successfully negotiated benefit improvements and changes to the PSHCP that came into effect July 1, 2023. Information about the improvements and changes can be found at canada.ca/pension-benefits Opens a new website in a new window . 

The improvements and changes to the PSHCP are unrelated to the change in plan administrator. Canada Life will administer your coverage based on the PSHCP Directive, which is available on the National Joint Council website at njc-cnm.gc.ca Opens a new website in a new window .

If you’ve completed positive enrolment for the Public Service Health Care Plan (PSHCP), you’re set up in our system to have your claims reimbursed. 

Your pharmacist needs your certificate and plan number (the information on your PSHCP benefit card) to accurately submit claims to Canada Life. 

Your certificate number is the same as it was with Sun Life and can be found on an old explanation of benefits or on your old benefit card. However, your plan number changed based on your month of birth:

  • (52111) January, February, March
  • (52112) April, May, June
  • (52113) July, August, September
  • (52114) October, November, December
  • (52115) the plan number for eligible surviving dependants (spouse or eligible children) 

Please note that these numbers are the same for you and your eligible dependants. 

Additionally, please ask them to confirm if they’ve correctly entered the following information:

  • Carrier number 12
  • Your plan number (based on your birth month)
  • Certificate number (the same as it was with Sun Life)
  • Card issue number 01

Effective July 1, 2023, prescription drugs under the Public Service Health Care Plan (PSHCP) are subject to mandatory generic substitution. This means that the PSHCP provides coverage for eligible prescription drugs at 80% of the lowest-cost generic drug when a generic is available. Generic drugs are approved by Health Canada and are pharmaceutically equivalent to the brand name drug as they contain the identical medicinal ingredients. 

If you were taking a brand name drug prior to July 1, 2023, the PSHCP will provide a legacy period ending December 31, 2023. During the legacy period, prescribed brand name drugs will still be reimbursed at 80% of their cost for those with existing prescriptions. Before this period ends, discuss the 3 options below with your health care provider. 

If you have a prescription for a brand name drug and a generic version is available, there are 3 options: 

  • Purchase the generic drug. The PSHCP will reimburse 80% of the eligible cost.
  • Purchase the brand name drug. The PSHCP will reimburse 80% of the cost of the generic drug and you’ll have a higher out-of-pocket cost (this is known as the co-payment amount).For example, a brand name drug costs $100 and the generic costs $80. If you purchase the generic, the PSHCP will cover 80% of the $80 charge, which is $64. Your out-of-pocket amount is $16. If you choose to purchase the brand name, the PSHCP will still cover $64, but your out-of-pocket amount will be $36. 
  • If there’s a medical reason why you cannot take the generic drug, have your doctor complete a PSHCP – "Request for brand name drug coverage" form, available on the Forms page on the PSHCP Member Services website. Any fees your physician may charge for providing this information will not be reimbursed. Submit the completed form to Canada Life at the mailing address, email address or fax number on the form .Please allow 7 to 10 business days to complete a review of the medical information provided. Canada Life will send a letter outlining the decision.

The pharmacy’s computer system believes that you or your dependant under the Public Service Health Care Plan (PSHCP) has “Other insurance” (OI). 

OI can be other private insurance or provincial/territorial health insurance. 

There are different intervention codes for private insurance and provincial/territorial health insurance. If your pharmacy has entered the wrong intervention code, a “DIN Covered by Other” message might appear. 

This message will also appear if your pharmacy has entered an intervention code when OI does not exist. 

Confirm with your pharmacy that they have entered the correct intervention code. If you or your dependants do not have any OI, you can easily update this information on your PSHCP Member Services account Opens a new website in a new window . Simply go to the 'Your Profile' section and select 'Dependants and other Coverage'. Then click on 'Your other Coverage' and make the necessary updates. 

Any updates made to your PSHCP Member Services account may take 1 to 2 days to take effect.

This error will show up in 2 cases:

  • The pharmacy has entered a date of birth that does not match what’s in your positive enrolment information in our system.
  • The date of birth provided by the pharmacy is correct, but they mistakenly entered the wrong relationship code. For example, the medication is meant for your dependant, but the pharmacist entered the relationship code 01, which is intended for you, the plan member.

Please inform the pharmacy about the patient's relationship with you as the plan member.

To check the list of dependants covered under your Public Service Health Care Plan (PSHCP), navigate to 'Your Profile' and select 'Dependants and other Coverage'. 

If you cannot add a dependant or the option is not available for you, please ensure that you have changed your coverage level from ‘Single’ to ‘Family’. If you need to change your coverage from Single to Family, or vice versa:

  • Active employees can amend their coverage type through the secure online Compensation Web Application (CWA). If you cannot access the CWA, you may complete a paper application form and submit it to your departmental compensation office or Pay Centre Opens a new website in a new window .
  • Retired members can submit a paper application form to their pension office. 

A waiting period may be applied by your employer, and Canada Life will not receive notice of this change until it is finalized. Your file will be updated to allow you to add a dependant in your PSHCP Member Services account once your employer or pension office informs us that your change request has been authorized.

To update your address for the Public Service Health Care Plan (PSHCP), sign in to your PSHCP Member Services account. 

Navigate to the 'Your Profile' tab and select 'Personal Information.'

Our Benefit Payment Office service turnaround time is measured from the date the claim is received to the date the claim is resolved. 

Our average service level is as follows:

  • Electronic claims  – 5 calendar days
  • Paper claims (except out-of-province)  – 9 calendar days
  • Out-of-province claims  – 10 calendar days
  • Comprehensive Coverage claims  – 10 calendar days 

We might occasionally exceed the above service levels due to:

  • Experiencing higher claim volumes
  • Claims that are complex and require additional review

Please allow 1 to 2 days from the submission date to show up on your Claim History.

Sun Life will continue to process claims that were pending before July 1, 2023. Please check your Sun Life Member Services account. 

If you cannot find the information on your Sun Life Member Services account, you can resubmit the claim to Canada Life. 

Please note that if claims get paid by both Sun Life and Canada Life, the resulting overpayment will be collected.

If you’ve processed Public Service Health Care Plan (PSHCP) claims through Sun Life, you may access the report by signing into your Sun Life Member Services account. 

Similarly, for claims processed by Canada Life, you may download them from your Canada Life PSHCP Member Services account.  You may also call the PSHCP Member Contact Centre at 1-855-415-4414 Opens in a new window , Monday to Friday from 8 am to 5 pm, your local time, to request a paper report be sent to you in the mail.

Plastic benefit cards will not be issued for the Public Service Health Care Plan (PSHCP). This is a green initiative supported by the Government of Canada and Canada Life. You may access your PSHCP benefit card for yourself and your covered dependants through the PSHCP Member Services website and save it to your mobile device and/or print it. You may also call the PSHCP Member Contact Centre at 1-855-415-4414 Opens in a new window , Monday to Friday from 8 am to 5 pm, your local time, to request a paper PSHCP benefit card be sent to you in the mail. 

If you have difficulty downloading your card once you’ve located it, log out, check to see that your browser is permitting pop-ups and then try again.

If you’ve completed positive enrolment for the Public Service Health Care Plan (PSHCP), but your claim is still not going through at the pharmacy, ask the pharmacist to confirm the following:

  • Did the pharmacist enter your new plan number and your existing certificate number? These numbers can be found on your new Canada Life PSHCP benefit card.
  • (52115) the plan number for eligible surviving dependants (spouse or eligible children)
  • Did the pharmacist select “Carrier 12” which is the unique number associated with the PSHCP? The carrier number is the same as it was with Sun Life.
  • Did the pharmacist enter the TELUS provider number associated with PSHCP Carrier 12, and not the provider number used with Canada Life’s other clients?  

When your pharmacist submits claims for your eligible dependants (spouse, common-law partner or eligible children) your pharmacist will need to enter their name exactly as you did when you completed positive enrolment. If you want to verify the spelling used during positive enrolment, sign in to your PSHCP Member Services account through the PSHCP Member Services website or the positive enrolment confirmation package you received in the mail, to see your dependants.

Positive enrolment (PE) is a mandatory process by which you provide information about yourself and, if applicable, your eligible spouse or common-law partner and each eligible dependant child eligible for coverage under the PSHCP. Members must also provide consent for Canada Life’s use of this personal information to process their PSHCP benefits. 

This information is vital for all members covered under the PSHCP. If you do not complete positive enrolment, your health care claims will not be processed or reimbursed. 

If there is information that cannot be updated or corrected through the positive enrolment process, please contact your pension or compensation office.

New plan members to the PSHCP or members who haven’t received a positive enrolment email or package in the mail, can visit the top of this page and click on the link to complete positive enrolment Opens a new website in a new window .

Your certificate number will remain the same, however, your plan number will change. Your new plan number is based on your month of birth:  

  • (52111) January, February, March 
  • (52112) April, May, June 
  • (52113) July, August, September 
  • (52114) October, November, December 
  • The plan number will be 52115 for eligible and surviving dependants (spouse or eligible children) 

Following the positive enrolment process, you’ll receive your PSHCP benefit card, either on your account through the PSHCP Member Services website or mailed to your home if you requested paper delivery. You can find both these numbers on your benefit card.

If you complete your positive enrolment with Canada Life online, you’ll have access to a new digital PSHCP benefit card right away. If you complete your positive enrolment by paper, you’ll be mailed a confirmation of enrolment that includes a new paper PSHCP benefit card, approximately 4 weeks after Canada Life receives your positive enrolment form.

You may notice that only the first 3 letters of your first name appear during Positive Enrolment. Rest assured we have your correct information from your Employer or pension office. Work is underway to display your full name in our system. Please note this will not affect your benefit coverage. If you notice a discrepancy with your last name or date of birth, please contact your departmental compensation office, Pay Centre, Pension Centre to update this information. Canada Life cannot update this information for you.

Canada Life is developing a customized PSHCP application for you.

In the meantime, you can use your mobile accessible PSHCP account online through the Canada Life PSHCP Member Services website, linked at the top of this page.

Positive enrolment must be completed and consent must be provided to have your claims processed by Canada Life after July 1, 2023. You will not be able to both complete positive enrolment and send in a claim on the same day. Allow at least 48 hours for your positive enrolment to process.

Complete your positive enrolment today to avoid being out of pocket for your health claim expenses.

Plastic benefit cards will not be issued for the Public Service Health Care Plan. This is a green initiative that is supported by the Government of Canada and Canada Life. 

You can access your PSHCP benefit card through the Canada Life PSHCP Member Services website, linked at the top of this page, to save it to your mobile device or to print a copy. Alternatively, call our Member Contact Centre at 1-855-415-4414 Opens in a new window , Monday to Friday from 8 am to 5 pm your local time, to request a paper PSHCP benefit card be sent to you in the mail.

While Canada Life was able to securely transfer some of your personal information from Sun Life, it’s still important that we receive your most up-to-date information and your consent. Your consent is required for Canada Life to use your personal information to administer the Plan, and to adjudicate and pay your claims.

CANADA BUZZ

coordination of benefits canada

What is Coordination of Benefits (COBS)?

Canada buzz editorial.

  • February 24, 2023

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A Stethoscope Around A Family Portrait

Canadians can have more than one health insurance plan or provider, depending on their needs. There are ways for you to maximize the coverage of your medical services, including prescription drugs and dental services. You can achieve managing two or more insurance policies via Coordination of Benefits (COBS).

This article will be reviewing the Coordination of Benefits in Canada and what it entails.

Coordination of Benefits

Coordination of benefits is a standard provision in health plans and benefit carriers in Canada. It allows individuals, couples, and families with more than one health plan to receive full coverage for medical services.

That is, as a member of a health plan or benefits carrier, you can get up to the maximum amount for eligible prescription drugs, dental and health claims. In addition, you and your spouse or common-law partners can benefit from each other’s plans.

Although, as an individual, you can also coordinate the benefits of more than one private health plan. However, it is only applicable when the combined reimbursement from all the plans cannot be more than the incurred expenses.

Features of Coordination of Benefits

The Coordination of Benefits is systematically designed to fit every lifestyle. Hence, there are different features regardless of your status. Below is how Coordination of Benefits facilitates your plans:

For an individual

As an individual with multiple plans, your coverage determines the position of the plans. Also, your health claims will be divided proportionately between the plans.

For married couples

Each spouse’s plan is considered the primary plan. And any outstanding claims will be sent to the other spouse’s plan and regarded as the secondary plan.

Also, for direct bill plans like dental plans and prescription drugs, the provider will submit the claims to the appropriate benefit carriers on their behalf.

For instance, Susan and David are a couple. When they submit their claims to their primary health plan or benefit carriers, they will each receive an Explanation of Benefits . Afterward, Susan’s outstanding claims will be sent to David’s benefits carrier, and David’s outstanding claims will be sent to Susan’s plan or benefits carrier.

For families with dependent children

The parent whose birthday falls earlier in the calendar year will be the primary plan holder for the children. For instance, if you have your birthday earlier than your spouse, you will be the holder of the primary plan for your children. Conversely, if it’s your spouse, they will be the holder of the primary plan.

If you and your spouse have the same birth month regardless of birth year, whoever has the earlier birthday gets to be the primary plan holder. Also, if you share the same birthday, the spouse whose first letter of their official name is closest to the beginning of the alphabet (the letter ‘A’) will be the primary plan holder.

Based on the example above, if Susan and David have the same birthday, David will be considered the primary plan holder for their children.

For divorced or separated parents

The coordination of benefits for dependent children is similar to that of the married parents, except one of the parents wants sole custody. If you want sole custody for your dependent child or children as a divorced or separated parent, you will reach out to your carrier for details on the process.

How Coordination of Benefits Works

Coordination of benefits varies with each health plan or benefits carrier. Hence, you have to consult your health plan contract or benefits carrier for information on how to go about it.

There is a general framework for the coordination of benefits. The framework requires that you submit claims to your primary benefit carrier or health plan for review.

Also, you have to submit all payments according to your coverage and benefits. Afterwards, you will then receive an Explanation of Benefits or a statement. Once you receive this, you can proceed to submit a claim for the eligible unpaid amount to your second plan or your spouse’s or common-law partner’s plan.

In coordination of benefits, there’s the preliminary plan and the secondary plan. However, if you have more than one health plan as an individual, a couple or family, it is up to you to determine which plan is primary and secondary. In addition, the preliminary plan always pays first while the secondary plan settles outstanding payments.

Coordination of Benefits for Public Service Health Care Plan (PSHCP)

Coordination of benefits between two PSHCPs is allowed for members of the PSHCP. To be eligible to coordinate your benefits, you will need to have family coverage and complete the positive enrolment to include your spouse or common-law partner. All you have to do is complete the coordination of the benefits section when submitting a PSHCP claim.

Coordination of benefits is a great way to get maximum coverage for health and medical services in Canada. It is for individuals, couples, and families with more than one health plan or benefits carrier. Also, members of the Public Service Health Care Plan can leverage coordinated benefits if they have more than one provider.

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Canada Buzz is a purely informational blog.  Opinions expressed on this blog are NOT endorsed by the reviewed brands. The information provided on this website does not constitute financial or professional advice. However, our team strives to bring you quality, unbiased information. What’s in it for us? One of the ways we get rewarded is via ads and affiliates. This website contains ads and affiliate links and we may receive compensation when you click any of these links.

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Benefits Canada.com

Guidelines for coordinating benefits with an HCSA

  • March 15, 2011 September 13, 2019

Guidelines for coordinating benefits with an HCSA

With the prevalence of healthcare spending accounts (HCSAs) on the rise, employees who are able to take advantage of coordinating health and dental benefits with a spouse are asking for clarification as to where they should submit their claims for payment, explains a recent News & Views from Morneau Shepell.

The Canadian Life and Health Insurance Association (CLHIA) sets Coordination of Benefits (COB) guidelines that give direction on determining priority in payment of claims and promote consistency across carrier, but the association has determined that an HCSA is not subject to these guidelines.

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Canadian Dental Care Plan

Service Canada is aware of scams targeting Canadians related to the Canadian Dental Care Plan (CDCP). If you are concerned about the legitimacy of a letter you received regarding CDCP, you can contact 1-833-537-4342 (TTY: 1-833-677-6262).

The Canadian Dental Care Plan (CDCP) will help ease financial barriers to accessing oral health care for eligible Canadian residents.

Applications will open in phases starting with seniors . Find out when you can apply .

Other coverage for families with young children

If you're a parent or guardian of a child under the age of 12, and you do not have access to dental insurance, you may already be eligible for the Canada Dental Benefit. This benefit is available until June 30, 2024.

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Annual Pensioner’s Statement: February 2024—Public Service Pension Plan

The Annual Pensioner’s Statement has details about your monthly pension and provides you with an overview of your pension and benefits. Below, you will find the articles included in the statement.

On this page

Annual indexing, important information about your pension entitlements.

  • 2023 Tax statements

Do you have to pay income tax every year when you file your tax return

  • Information on survivor pension

Will you be returning to work after retirement

Important reminders, contact information.

The annual indexing rate for 2024 is 4.8%.

In most cases, if you retired before 2023, the full indexing rate will be applied to your pension in January 2024. If you retired in 2023, a prorated indexing rate based on the number of full calendar months remaining in 2023 will be applied to your pension. For example, if you retired in November 2023, your indexing rate would be 1/12 of the full year (December only), starting in January 2024. The indexing rate also applies to the survivor pension. For more information on how the indexing is applied, visit Pension and benefits .

Your public service pension is made up of two parts:

  • a lifetime pension
  • a temporary bridge benefit which ends at age 65 or earlier if you become eligible to receive Canada Pension Plan (CPP) or Quebec Pension Plan (QPP) disability benefits

Important: You must inform the Pension Centre immediately if you become eligible to receive a CPP or QPP disability benefit. Failure to do so could result in an overpayment of your pension, which you’ll be required to repay.

If you have questions about your CPP or Old Age Security (OAS) benefits, please contact Service Canada at 1‑800‑277‑9914. If you have questions about your QPP benefits, please contact Retraite Québec at 1‑800‑463‑5185.

2023 tax statements

A hard copy of your year-end tax statements will be mailed by the end of February and you should receive them by March 15, 2024. Did you know that if you register with My Account on the Canada Revenue Agency’s (CRA) portal at Canada.ca/my-cra-account , you’ll have access to your year-end tax statements and all other available services. My Account is a convenient and secure way to view your year-end tax statements.

If you have to pay income tax every year when you file your tax return, you can request that more tax be deducted from your monthly pension. To do so, call the Pension Centre or send them a completed TD1—Personal Tax Credits Return form . Consult the Canada Revenue Agency—Taxes website or call 1‑800‑959‑8281 for more information.

Information on Survivor Pension

Your married or common-law spouse may receive a survivor pension if you married or began living in a common-law relationship before you retired and that union remains constant until you pass away. If you married after retirement, you may elect to provide your married spouse with the Optional Survivor Benefit (OSB) by taking a reduction in your own pension. This option must be made within 1 year of marriage or 1 year from your pension start date, whichever is later. For more information on survivor benefits, visit Pension and benefits .

If you accept employment in the public service and meet the eligibility criteria to contribute to the public service pension plan, your monthly pension payments will be affected. Your ongoing pension payments will be stopped and only restart once you are no longer employed in the public service. Your future pension will be recalculated to include the additional period of service and your indexing will be based on your new employment end date. For more information on re-employment after retirement, visit Pension and benefits .

  • Keep your February Annual Pensioner’s Statement or your most recent Direct Deposit Payment Statement for reference. A Direct Deposit Payment Statement is only issued when the net pension amount changes by $2 or more
  • Verify your most recent statement to ensure your address and banking information are up to date and inform the Government of Canada Pension Centre of any changes
  • Inform your family that they need to contact the Pension Centre immediately following your death. This will ensure timely payment of survivor benefits and prevent any overpayment of your pension

Call Monday to Friday

Have your pension number ready.

Visit Pension and benefits

Government of Canada Pension Centre Mail Facility PO  Box 8000 Matane  QC  G4W 4T6

To allow us to access your pension file, please provide your:

  • pension number
  • surname, first name and initials
  • address (with postal code)
  • telephone number (with area code)

IMAGES

  1. What is Coordination of Benefits?

    coordination of benefits canada

  2. Coordination of Benefits

    coordination of benefits canada

  3. Coordination of Benefits With Multiple Insurance Plans

    coordination of benefits canada

  4. Coordination of Benefits Services

    coordination of benefits canada

  5. Cigna coordination of benefits: Fill out & sign online

    coordination of benefits canada

  6. Coordination of Benefits vs. Explanation of Benefits

    coordination of benefits canada

COMMENTS

  1. What is coordination of benefits?

    What is coordination of benefits? Dec. 7, 2021 3 min read Key takeaways When someone is covered by more than one benefits plan, the plans work together to pay any claims. There are several scenarios to determine which plan pays first. The reimbursement under both plans won't be more than 100% of the original claim amount. What's in this article?

  2. Coordination of Benefits: Can I Have More Than One Benefit Plan?

    Coordinating Benefits When you choose to coordinate benefits, you indicate a desire to be covered by both plans. Like waiving coverage, you can choose to coordinate benefits for yourself and your dependents, or yourself only. Coordinating your benefits is like having a back-up plan to cover additional expenses not covered by the first plan.

  3. PDF Understanding Coordination of Benefits (COB)

    COB is standard practice among benefits carriers in Canada and allows people with more than one plan to maximize their coverage. How does it work? With COB, you submit claims to your benefits carrier first for adjudication and payment according to your coverage and benefits.

  4. Public Service Health Care Plan

    Coordination of Benefits is a provision that determines the sequencing of coverage when Plan members and their dependents are eligible for benefits under more than one private health care plan. The PSHCP uses the benefit coordination guidelines established by the Canadian Life and Health Insurance Association (CLHIA).

  5. Submit a claim to more than one plan

    Submit a claim to more than one plan Also called coordination of benefits or COB Back Covered by more than one benefit plan? You can send the same claim to all the plans. You could get back the full amount you claim. Keep copies of your statement and receipts - including drug receipts. Each plan will tell you what you need to send with your claim .

  6. What is Coordination of Benefits?

    1. Understanding COB COB is a provision that says your insurance company will review and pay your claims only after the primary payer, has paid its portion of the bill. While COB benefits are intended to limit administrative costs, a primary payer is the patient's last connection to the health care system when all claims are paid.

  7. Coordination of Benefits

    Member Centre / Members Articles / Coordination of Benefits Coordination of Benefits Are you and your spouse covered by separate benefit plans? Then you may be able to enjoy reimbursement for up to 100% of eligible claims through Co-ordination of Benefits. How does it work? Is the claim for you?

  8. Submitting a benefit claim

    Coordination of benefits between two Public Service Health Care Plan (PSHCP) members is allowed. To coordinate benefits under the PSHCP you must have Family Coverage and complete positive enrolment to include your spouse/common-law partner. See Getting Married or Reaching Common-Law Status.

  9. PDF Coordination of benefits

    Coordination of benefits TO GET THE MOST OUT OF YOUR INSURANCE COVERAGE What does "coordination of benefits" mean? When different members of the same family have jobs, or multiple jobs, or are enrolled in an educational institution, they may have health or dental care coverage under more than one group insurance plan.

  10. How To Coordinate Your Personal and Group Health Benefit Claims

    The Coordination of Benefits Provision limits the total benefit amount you can claim, up to a combined maximum of 100 percent of the cost of the eligible expenses incurred. This means that any overlapping coverage you have on a specific claim will not result in you receiving total payments greater than the actual cost of the claim you submitted.

  11. PDF McGill University

    McGill University

  12. Coordination of Benefits

    Guideline G4 The CLHIA has developed this Guideline for the health and dental benefits industry to help promote consistency in determining the priority in which payments are made and to outline the minimum amount payable by each Group Plan in situations where a Covered Individual can submit a claim to more than one Group Plan.

  13. How-to Guide for Coordinating Benefits

    1. Click on "Submit a Claim". 2. Click on "My Claims" under the Claims tab. 3. Click on "Coordination of Benefits" and answer the questions as indicated. Your spouse or partner must also set-up their Sun Life account to allow for coordination of benefits before COB claims may be submitted. Any extended health and/or dental claims ...

  14. Benefits for retired members: Plan members on or before December 31

    Section 4: Coordination of benefits with the Canada and Quebec Pension Plans. When the Canada Pension Plan (CPP) and Quebec Pension Plan (QPP) came into effect on January 1, 1966, the contribution rates under the federal public service pension plan were coordinated with those under the CPP and QPP rather than added to them. Since contributions ...

  15. Coordination of benefits

    SEE Canada Grant Learning and Development Learning and Development ... What is coordination of benefits (COB)? If you and your dependents are covered for extended healthcare and/or dental benefits under more than one plan, your reimbursement will be coordinated following insurance industry standards. The maximum amount that you can receive from ...

  16. Canadian Life and Health Insurance Association

    Guideline G12. This Guideline sets out regulators' expectations regarding the rights and duties of plan members, sponsors and service providers relating to employer-sponsored, tax assisted, savings plans known as Capital Accumulation Plans ("CAPs"). The Guideline also recommends comparable practices for non-tax-assisted plans.

  17. PSHCP FAQ and support

    Coordination of benefits: You may submit coordination of benefit claims between 2 Canada Life plans or submit the remaining balance of a claim already processed by another benefit plan. Positive enrolment: You may complete or update your positive enrolment information, including direct deposit information.

  18. Coordinating Benefits with Multiple Plans

    This process is called Coordination of Benefits, or COB, and it's a standard practice for benefit providers across Canada. How Does it Work? When a claim is submitted, you'll receive an Explanation of Benefits (EOB) statement—available on My ASEBP —which outlines how much your plan covers.

  19. Submitting a benefit claim

    In situations where coordination of benefits is allowed, the combined reimbursement from all Plans cannot exceed the expenses incurred. Coordination of benefits between two Public Service Health Care Plan (PSHCP) members is allowed. ... (PSHCP) benefit card from Canada Life, you must be enrolled in the PSHCP and have completed positive enrolment.

  20. What is Coordination of Benefits (COBS)?

    Coordination of benefits is a standard provision in health plans and benefit carriers in Canada. It allows individuals, couples, and families with more than one health plan to receive full coverage for medical services.

  21. Guidelines for coordinating benefits with an HCSA

    The Canadian Life and Health Insurance Association (CLHIA) sets Coordination of Benefits (COB) guidelines that give direction on determining priority in payment of claims and promote consistency ...

  22. PSHCP Coordination of Benefits : r/CanadaPublicServants

    I am having a similar issue. Both my spouse and I are public servants, and while her profile correctly shows myself and our children as dependants and allows for coordination of benefits, mine does not. When I use the same URL for the dependants benefit page when I am logged in, I can see that my spouse and children are also listed as ...

  23. Canadian Dental Care Plan

    Service Canada is aware of scams targeting Canadians related to the Canadian Dental Care Plan (CDCP). If you are concerned about the legitimacy of a letter you received regarding CDCP, you can contact 1-833-537-4342 (TTY: 1-833-677-6262). ... This benefit is available until June 30, 2024. Sections Do you qualify Find out if you're eligible for ...

  24. Coordination of Benefit with CanadaLife

    1. dogdr • 2 mo. ago. The coordination of benefits function was broken for claims you submitted yourself online until late in the day on September 20 (as in July 1-September 21). Anything submitted after the fix should automatically coordinate (provided you answer the questions about having other coverage properly).

  25. Annual Pensioner's Statement: February 2024

    a temporary bridge benefit which ends at age 65 or earlier if you become eligible to receive Canada Pension Plan (CPP) or Quebec Pension Plan (QPP) disability benefits; Important: You must inform the Pension Centre immediately if you become eligible to receive a CPP or QPP disability benefit. Failure to do so could result in an overpayment of ...