prince dnwian...• the child disability benefit (cdb) is a tax-free benefit for families with a...
TRANSCRIPT
Who pays for H E A LT H C A R E ?
We gathered the information in this guide as of May 3, 2014. We’ve made a considerable effort to confirm that the information is accurate, but it may be incomplete or incorrect.
It’s important that you consult your own legal and tax advisors to review your personal situation. We also recommend you check your employer and personal insurance plans for details on your specific coverage.
PRINCE EDWARD ISLAND
HOMECARE
LONG TERM CARE
PALLIATIVE CARE
PRESCRIPTION DRUGS
TRAVEL EMERGENCY HEALTH
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Health always matters most
Canadians strongly identify with their medicare system and most see it as a national icon. We have enjoyed universal, first-dollar coverage for hospitals and physicians for decades, but other health services can be surprisingly expensive.
Our needs have changed over time, often radically. While the principles of the Canada Health Act (1984) remain sound, in the last 30 years there has been a six-fold increase in health costs.1 Private health spending by individuals and insurers was estimated at $63 billion in 2013. Some of those costs likely came from your pocket…or may soon.
Planning and paying : A shared responsibi l i ty
Government and employer health plans provide complementary coverage for many health-related expenses. But there are common, medically necessary health services that are not fully covered. Each province makes their own decisions and those entitlements may change over time, especially as governments struggle with high debts and deficits, demographic changes and higher rates of many common chronic diseases such as diabetes, certain
cancers and dementia. In this context of change, we recommend you consider your own needs, preferences and personal resources. Planning for health expenses is as important as buying a house or saving for retirement; indeed, health and wealth planning are natural companions.
Introducing Sun L i fe’s healthcare funding guides
These guides outline some of the coverage options, personal costs and other key considerations for six common health events and services: disability, home care, long term (nursing home) care, palliative (end-of-life) care, prescription drugs and travel emergency medical.
The guides are organized by province, just as our healthcare system is operated and you’ll find many embedded web links to other authoritative websites for more detail and the latest updates. They are meant to be a quick reference that you will find practical, informative and easily accessible. Planning ahead can provide important protection and peace of mind and help you get what you need, when you need it.
Research provided by H3 Consulting. 1 Canadian Institute for Health Information, 2013. National Health Expenditure Trends 1975 to 2013 (Link: https://secure.cihi.ca/free_products/NHEXTrendsReport_EN.pdf).
INTRODUCTION
HOMECARE
LONG TERM CARE
PALLIATIVE CARE
PRESCRIPTION DRUGS
TRAVEL EMERGENCY HEALTH
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Overview
Disability can affect your income, lifespan and quality of life and your chances of becoming disabled are greater than you may think. Statistics Canada has reported that nearly 4.5 million Canadians (14.3%) had a disability in 2006. That percentage has increased since 2001 and also increases steadily with age. Among younger people of working age (25-44), 8% reported a disability. For those ages 45-64, 18% reported a disability. For all adults, the most frequent disabilities are related to pain, mobility and agility and of those reporting a disability, 82% reported more than one and 40% reported their disability was severe or very severe.
COVERAGE Federal government
• The Canada Pension Plan (CPP) provides a disability benefit to those under age 65 who have contributed to the plan and who have a severe and prolonged disability that 1) prevents a claimant from being able to work at any job on a regular basis or 2) will result in death. Applications take about four months to be processed, although those considering terminal conditions will be reviewed in two days. As of March 2014, the average monthly benefit is $896.87 and the maximum benefit for 2014 is $1,236.35. The basic amount ($457.60 - 2014) is fixed for all eligible claimants, with additional benefits based on the claimant’s CPP contributions. If the claimant qualifies, there is also an additional benefit for dependent children payable up to age 25. The current (2014) benefit is a flat monthly rate of $230.72.
• Employment Insurance (EI) pays a sickness benefit for up to 15 weeks for those unable to work due to sickness, injury or quarantine. Your earnings
must have dropped at least 40% due to your condition and you must have at least 600 hours of insurable earnings during (generally) the last 52 weeks. There is a two-week waiting period once approved. Based on 55% of your insurable earnings, the maximum weekly benefit was $514 in 2014, but there is a supplement for qualifying low income families.
• The Child Disability Benefit (CDB) is a tax-free benefit for families with a child under age 18 who has a severe and prolonged impairment in mental or physical function. The CDB provides up to $218.83 per month for each eligible child (July 2013 - June 2014) but is reduced according to the number of children and family net income.
• Veterans and active military personnel may qualify for a disability award or a disability pension if their disability is related to their military service. Current and former members of the RCMP and certain civilians may also qualify for the disability pension.
4.5 million(14.3%) of Canadians had a disability in 2006
14.3%
25-44 years8%
45-64 years
Reported disabilities more than double after age 45
18%
DISABILITY PROTECTION
Most frequent disabilities are related to
PAIN,mobility
agilityand
HOMECARE
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PALLIATIVE CARE
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• For severe and prolonged disability in physical or mental functions, there are other federal tax benefits for which you may qualify, including the Disability Tax Credit (DTC). For those who qualify for the DTC, contributions can be made to a Registered Disability Savings Plan (RDSP). Those with a RDSP are eligible for federal grants and bonds.
COVERAGE Provincial government
• The Disability Support Program (DSP) assists with personal planning and provides supports for adults and children and for employment and vocational services. Respite care is offered, as well as funding for intensive behavioral intervention for children with Autism Spectrum Disorder, community living and community participation supports, technical equipment and family support programs. Individuals will be required to sign an individual support agreement.
• Section eight of the DSP Policy Manual provides:
◊ Various technical aids and assistive devices that are cost-shared following the recommendation of a health professional such as an occupational therapist, physiotherapist, audiologist or speech language pathologist. Examples include aids for the bathroom or bedroom, ostomy supplies, communication devices, feeding equipment, hearing aids, orthotics, prosthetics, visual aids and mobility aids such as wheelchairs and walkers.
◊ Modifications for: 1) a home to a lifetime maximum of $2,000, 2) a vehicle to a lifetime maximum of $2,000 or 3) a place of employment to a maximum of $3,000.
◊ Employment supports such as workplace and vocational assessments, training and coaching, job placement, training allowances, etc.
• Income support for those with disabilities is provided through the Social Assistance Program, which provides income for general necessities, home rehabilitation, medical, dental and vision care and assistance with funeral costs. Payments vary depending on the number of dependants and whether the applicant owns a home.
• The Workers Compensation Board of PEI (WCB PE) provides income replacement benefits and healthcare coverage for qualified workers through no-fault liability insurance mandated for employers in certain industries. Following a short unpaid waiting period, temporary and extended wage loss benefits are paid at 85% of your net earnings up to $51,100 (2014). Various healthcare and prescription drug benefits are also provided. Survivors also have access to benefits, including a lump-sum payment of $10,000 and ongoing benefits. Expect monthly benefits to be coordinated with other sources such as employer-sponsored short and long term disability benefits, CPP disability benefits and EI sickness benefits.
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DISABILITY PROTECTION
COVERAGE Provincial governmentCOVERAGE Employer plans
• Many larger employers and some smaller ones, provide compensation when you cannot work due to disability. These include partial or full pay under casual absence or sick leave programs, or benefits paid under short term disability and/or long term disability (LTD) insurance plans. Those benefits may be provided by the employer directly, through a health and welfare trust, via third-party administrator or by an insurer. Benefits payable under an LTD insurance plan will be taxable if the employer paid any part of the monthly premium. Benefits are typically paid at between 60% and 75% of earnings and may be offset by benefits paid from other sources, such as Workers’ Compensation or CPP. There will be a waiting period before benefits are payable, which is usually between three and six months following the first day of disability. If your employer has a flexible benefits plan, you may be able to choose the amount of disability coverage you want, but only once a year during an open enrolment period.
• Employers in certain industries and over a certain size are required to contribute to WCB PE to provide income replacement for occupational injuries and illnesses – those caused in the workplace.
COVERAGE Personal insurance
• Individual disability insurance plans are available directly through insurers, or through membership in various associations including post-secondary alumni associations. The risk of disability depends on factors such as your age, health risks, family medical history and your job. Applications require proof of good health to allow insurers to assess risk. Even if your health status is compromised, insurers may still provide coverage at a higher-than-standard rate, or they may provide coverage for all risks other than a condition already diagnosed. If one insurer declines to cover you, another may still offer you insurance. The benefit duration and amount may be selected by the applicant, but the benefit can’t be greater than a certain percentage of average annual earnings. Don’t forget to ask whether your benefit depends on you being unable to do your own job, or any job you’re qualified for based on criteria such as your age, education, income and experience.
Own job coverage is more expensive but provides greater certainty of the benefit you’ll receive. Some policies pay using the own job definition for the first two or five years and any job thereafter.
• Standard automobile insurance policies in Prince Edward Island provide disability benefits of up to $140 per week for no more than 104 weeks. There is a seven-day waiting period.
COVERAGE Out-of-pocket expenses
• The patient’s cost may be offset by: 1) voluntary/charitable organizations, such as the March of Dimes, The Easter Seals Society, Kiwanis, Rotary or Lions Clubs, 2) social assistance benefits, 3) Veteran’s Affairs (federal), 4) private insurance or 5) relatives and friends. You may want to pursue these or other sources of financial support.
• Under the Income Tax Act, certain health insurance premiums and other eligible medical expenses may count towards a tax credit when total medical expenses exceed the lesser of $2,152 (2013) or 3% of your net income.
If one insurer declines to cover you, another may still offer you insurance.
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COSTS
• Client contribution rates for the Disability Support Program vary according to income, number of dependents and level of functionality.
• Private disability insurance premiums can be expensive, but the benefits may be crucial if you do not have enough savings to replace your work income. You don’t pay tax on disability income benefits from your policy as long as you were the only one who paid all the premiums.
FOR HELP
The application for the CPP disability benefit is available online and by calling Service Canada: 800-277-9914.
The application for the EI sickness benefit is available online or by calling Service Canada: 800-206-7218.
More information on the CDB is available here or by calling 800-387-1193.
Veterans Affairs may be contacted at 866-522-2122, as well as by using the links under Federal Government in the Disability Protection section of this document.
The list of eligible medical expenses that qualify for the medical expense tax credit is here.
Information on federal programs is available through your local Service Canada office.
Detailed policies included in Prince Edward Island’s DSP are available here.
Government program information and assistance is available at:
PROGRAM CHARLOTTETOWN SUMMERSIDE MONTAGUE SOURIS O’LEARY
Social Assistance 368-5338 888-8397 838-0728 687-7170 859-8835
Disability Support 368-5996 432-2740 838-0190 859-8824 687-7016
General information for provincial mental health services is here.
Contact information for the WCB PE is available here. Telephone the board at 902-368-5680 or toll-free in Atlantic Canada at 800-237-5049. WCB PE forms for workers are available here. Employer forms are here.
DISABILITY PROTECTION
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Overview
Home care includes a wide range of services provided in the home and community that can address prevention, healthcare, palliative care, rehabilitation and social support for both clients and caregivers. Home care services are funded and delivered by Health Prince Edward Island. Home care includes short and long term care in the client’s home and palliative care for those in the final stage of life.
COVERAGE Provincial government
• If one requires home care, a case coordinator will meet with that person to complete an assessment. A physician’s referral is not required. The necessary care services for which a person is eligible will be determined based on their needs. Coordinators can also connect the person with community programs that offer additional supports, such as meal programs and adult day programs. The coordinator can arrange access to a social worker, dietitian (Charlottetown and Summerside only), enterostomal therapy (Montague and Souris only), respite care and occupational and physical therapy. The home care case coordinator will also complete an assessment to determine when someone is ready for admission to a long term care (nursing) home.
• The province provides two general home care service categories:
◊ Home support: Including 1) personal care such as dressing, bathing, toilet use, feeding and help with mobilization and 2) home support services such as light housekeeping, laundry, meal preparation and in-home respite services for caregivers.
◊ Nursing: Including assessment, health teaching, health monitoring and treatment, intravenous therapy, dressing changes, catheter care and medication management.
• Prince County offers tele-health home services that can remotely read blood pressure, pulse, temperature and oxygen levels, take live heart, lung and bowel sounds, view wounds, dressings and conduct measurements on glucose meters. Equipment rentals may also be available.
• The Home Oxygen Program (oxygen and related equipment) is available through Pharmacare. Clients must not allow smoking in their home.
HOME CARE
Home care includes• Prevention• Healthcare• Palliative care• Rehabilitation• Social support
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HOME CARE• For those aged 65 and older, the Seniors’
Drug Cost Assistance Program covers the cost of many prescription drugs. There are 24 other provincial drug programs, including the Catastrophic Drug Program and the High Cost Drug Program, which may be helpful to those in home care. For more detail, see the section on Prescription Drugs in the Prince Edward Island guide.
COVERAGE Employer plans
• Home care services are typically excluded from extended health benefit plans available through your workplace. Most health plans provide limited supplemental coverage for private nursing care for employees and eligible dependents which can be accessed if more home care services are needed. Dependents are limited to the spouse and children. Some flexible benefit plans include a health spending account (HSA) which may be used to claim home care services. However, HSAs typically offer limited funds to cover a wide variety of healthcare expenses based on provisions in the Income Tax Act.
COVERAGE Personal insurance
• Some individually purchased health insurance plans reimburse the cost of in-home nursing and/or home care services according to an approved plan of care. The benefits supplement the cost of services not covered by the government.
• Most long term care insurance policies (which may also include home care) provide coverage following a waiting period if you are functionally dependent, meaning that you need substantial assistance with two of six activities of daily living (dressing, eating, toileting, bathing, continence and transferring) or substantial supervision because of cognitive impairment. There are two types of plans: those that reimburse defined expenses such as in-home care or equipment rental and those that pay a monthly income-style benefit that can be used as needed. For more detail, see: Long term care > Personal insurance > Typical coverage.
Most health plans provide limited supplemental coverage
for private nursing care for employees and eligible dependents which can
be accessed if more home care services are needed.
Research done for the Institute for Research on Public Policy indicated unpaid services by caregivers to the elderly had an estimated market value of between $24 and $31 billion in 2007. There are some tax advantages provided to informal caregivers, including the federal caregiver amount tax credit. The Public Health Agency has produced a brochure to help caregivers look after themselves in stressful times.
THE CRUCIAL ROLE OF CAREGIVERS
HOMECARE
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HOME CARE
COVERAGE Out-of-pocket expenses
• Beyond what the government provides, additional health professional or personal care services may be privately contracted at the client’s cost.
• Under the Income Tax Act, certain health insurance premiums and other eligible medical expenses may count towards a tax credit when total medical expenses exceed the lesser of $2,152 (2013) or 3% of the client’s net income.
COSTS
• All home care services are available at no cost, although clients must provide any equipment and supplies they require. However, the number of hours paid by government for home support is limited. Clients may wish to organize and pay for additional care from home support workers. Home care does not pay for certain professional services such as respiratory or speech language therapy. The cost of the Home Oxygen Program is subsidized at 50% up to a monthly maximum of $200.
• The province’s 25 drug programs each have costs for the home care client, sometimes very significant ones. While the Seniors’ Drug Plan may cost clients about $20 per drug dispensed ($8.25 plus the pharmacist’s professional fee), the Catastrophic Drug Plan requires patients to pay up to 12% of their household income when it exceeds $100,000.
• Home Support Workers (HSW): HSWs provide most non-medical home services and can be hired outside the Home Care Program to help clients perform activities of daily living, as well as shopping, food preparation, laundry
and transportation. HSWs are not a regulated profession and cannot initiate or perform care without supervision.
• Taking Care Inc. has prepared a summary of typical costs for Prince Edward Island residents.
FOR HELP
Home Care Program offices are located in:
◊ Souris: 902-687-7096
◊ Montague: 902-838-0786
◊ Charlottetown: 902-368-4790
◊ Summerside: 902-888-8440
◊ O’Leary: 902-859-8730
The office of the provincial Home Care Program director is in Charlottetown, 902-620-3045.
The Home care referral form is here.
The Home oxygen application form is available on-line. For more information, phone 902-368-4947 or toll-free 877-577-3737.
Prince Edward Island Pharmacare may be contacted at 902-368-4947 or toll-free at 877-577-3737. Pharmacare forms are available here.
All home care services are available at no cost, although clients must
provide any equipment and supplies they require. However, the number
of hours paid by government for home support is limited.
HOMECARE
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Overview
There are eight private nursing homes and nine provincial nursing homes as reported by the province. Nursing homes are for those with greater care needs and are supervised at all times by a registered nurse. Other professional services are available, such as physiotherapy, occupational therapy, recreation and those provided by a social worker.
There are also 38 Community Care Facilities (CCF) which offer accommodation and personal support services for those in-between home care and nursing home care. All CCFs are privately owned. Residents must pay the full cost of accommodation, though limited financial assistance may be available in certain situations. Five facilities offer both nursing and community care services.
A standardized functional assessment for residency is conducted by committees in each region who represent hospitals, home care, housing and long term care programs.
COVERAGE Provincial government
• All long term care (LTC) facilities are inspected, licensed and regulated by the CCF and nursing homes board. The Department of Health and Wellness (Health PEI) has published operational and care service standards for private nursing homes (July 2011) and for CCFs (March 2009).
• Nursing home residents pay a fee for accommodation and to cover the costs of services like meals, housekeeping and building maintenance. Those fees are regulated and periodically increased. Healthcare services in all nursing homes are provided at no cost through Health PEI.
• Admission to a nursing home is normally limited to those who are at least 60 years old. Others may be considered if they require nursing home care and there is no other appropriate alternative.
• Accommodation fees are not automatically covered by medicare, so you’ll have to rely on personal resources, government pension or disability benefits, or individual health insurance policies if your fees are not fully subsidized.
COVERAGE Employer plans
• LTC services are excluded from extended health benefit plans available through your workplace. Some flexible benefit plans include a health spending account (HSA) which may be used to claim home care services. However, HSAs typically offer limited funds to cover a wide variety of healthcare expenses based on provisions in the Income Tax Act.
LONG TERM CARE
Healthcare services in all nursing homes are provided at no cost through Health
Prince Edward Island.
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LONG TERM CARE
COVERAGE Personal insurance
• Personal LTC insurance may be a good option depending on your age, health and financial means. A helpful model outlining the five stages of care was developed by Dr. Mark Frankel and his team at Taking Care Inc., an organization dedicated to helping caregivers navigate the elder-care system. The stages are: 1) independence, 2) interdependence, 3) supportive living, 4) crisis management and 5) dependence.
• Typical coverage: Terms and conditions of coverage vary in the market. Generally benefits are payable upon dependency, which may or may not include living in a long term care home. Definitions of dependency vary within the insurance industry. Dependency includes criteria for mental ability and when the insured person is unable to perform at least two of six specified activities of daily living: dressing, eating, toileting, bathing, continence and transferring. Some sample provisions follow:
• Benefit: An applicant selects a benefit that can range from $70 to $2,500 per week. Benefits may be paid weekly or monthly. Policies often include one-time or annual access to a person who can help plan care. In Canada, the maximum insurance benefit available is $10,000 per person per month from all LTC policies.
� Benefit period: The applicant typically chooses a plan that will pay for one, two, three, four or five years, or an unlimited period that ends with the insured person’s death.
� Benefit maximum: The applicant may be able to choose a maximum amount of coverage, such as $100,000, which is then reduced by each monthly benefit paid to the insured person.
� Waiting period: Benefits become payable typically between 30 and 90 days (but you can choose up to two years) after the policy’s definition of dependency is met.
� Premiums are paid monthly usually until death, or for a period such as two, 10, 20 or 25 years. Premiums are not paid while benefits are being received. LTC insurance premiums are typically guaranteed for the first five years and may be adjusted over the life of the policy.
� Optional benefits may include inflation protection, return of premiums upon death after the policy has been in force for a certain period of time and shared coverage where one spouse may draw additional coverage from the other spouse’s plan.
� All policies are somewhat different and have exclusions and limitations of coverage. They should be read carefully. Questions may be directed to your insurance agent.
All policies are somewhat different and all have exclusions
and limitations of coverage. They should be read carefully.
Questions may be directed to your insurance agent.
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LONG TERM CARE
COVERAGE Out-of-pocket expenses
• Given limited and uncertain provincial support and the expense of LTC insurance policy premiums policy premiums, your personal financial assets and income may be used to purchase supportive living and eventually a nursing home. Alternatively, you may need to rely on family and friends for caregiving services. But of course those financial and personal resources may not be enough if you lose your ability to live independently.
• Under the Income Tax Act, certain health insurance premiums and other eligible medical expenses may count towards a tax credit when total medical expenses exceed the lesser of $2,152 (2013) or 3% of your net income.
COSTS
• Residents are responsible for the cost of accommodation and their personal expenses. Private nursing homes set their own rates for accommodation charges, although residents may qualify for a government subsidy. The province will pay $77.60 per day for health services in private nursing homes.
• For provincial nursing homes, the cost for accommodation for those with a government subsidy is $77.60 per day (2012).2 Residents who have a net annual income less than $30,000 may qualify for a subsidy and can apply to the Long Term Care Subsidization Program. The same fee applies regardless of room size or the number of occupants.
• Taking Care Inc. has prepared a summary of typical costs for Prince Edward Island residents.
QUALITY
Before selecting a LTC home, you’ll want to be sure it is well-equipped to look after you or a loved one. Quality is difficult to objectively assess since it includes the facility and its professional and non-regulated staff, as well as its rooms, food, safety, and health, social and recreational services. Quality should be verified: consider a site visit, discussions with staff and seek references from current or former residents and family members. Check whether the home has been independently reviewed and compared against national standards. In Prince Edward Island, many homes are smaller and may be independently owned and operated. Quality can vary significantly, even at the same home over time. Some have been reviewed by Accreditation Canada. Look for a current Accreditation Canada certificate in the facility, or search Accreditation Canada’s website. Once on the website, click on the link titled “Find an Accredited Health Care Provider Now” located on the left side of the page to find an accredited provider.
2 Source: http://www.gov.pe.ca/photos/original/hlth_ltc_fs1.pdf. Viewed April 2014.
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LONG TERM CARE
FOR HELP
To check eligibility for admission to any nursing home (public or private), contact the closest home care office:
• O’Leary: Community Hospital, 902-859-8730.• Summerside: Wedgewood Manor, 902-888-8440.• Charlottetown: Hillsborough Hospital,
902-368-4790.• Montague: Riverview Manor, 902-838-0786. • Souris: Souris Hospital, 902-687-7096.
To apply for the government’s Long Term Care Subsidization Program, call toll-free 888-365-5313.
Professional colleges govern the conduct of many regulated health professionals, such as physicians, registered nurses, licensed practical nurses and others.
The Community Legal Information Association published Moving to a Community Care Facility or Nursing Home in 2010. It provides very useful information but may no longer be current in all areas. For example, provincial law changed in 2012 so that assets no longer need to be sold to pay for nursing home care.
Accreditation Canada’s website provides information for the public about its standards and provides a list of accredited facilities.
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COVERAGE Provincial government
• Access to palliative care services is coordinated through Home Care Program offices. Care may include medical, nursing and other professional care for pain and symptom management, respite care, emotional and spiritual support, counseling and bereavement support after a loved one’s death.
• Palliative services can be provided in the most appropriate setting including the home, long term care, community care facilities, palliative care units and palliative care beds in an acute care setting. There are five locations in Prince Edward Island that provide palliative care: Souris, Montague, Charlottetown, Summerside and O’Leary.
• Under the Employment Standards Act, the province provides for up to eight weeks of unpaid compassionate care leave when a family member has been diagnosed with a serious medical condition that is expected to result in death within 26 weeks. Bereavement leave provides for one paid day of absence upon the death of an immediate family member and up to two more days of unpaid leave. After six months of continuous service, family leave entitles an employee to unpaid leaves of absence of up to three days during a 12-month period to meet immediate and extended family responsibilities.
PALLIATIVE CARE
There are five locations in Prince Edward Island that provide palliative care: Souris, Montague,
Charlottetown, Summerside and O’Leary.
Overview
Palliative care refers to a variety of healthcare and support services provided as people near the end of their lives. It is intended to improve both the quality of life and the quality of death for patients and their families by addressing physical, psychosocial and spiritual needs. Advance care planning is needed. There is often a particular emphasis on pain relief. A recent national survey reported that while one quarter of respondents thought government paid for palliative services, 70% worried they didn’t have enough money to pay for their own care.
Palliative patients may be described as those diagnosed at the end stage of a terminal illness or disease. The focus of their care is to relieve pain and suffering and not treatment aimed at a cure. Care may take the form of physical, emotional, psychological, spiritual or practical support for both the patient and the family.
70% of national survey respondents
worried they didn’t have enough money to pay for their own palliative care
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PALLIATIVE CARE
COVERAGE Employer plans
• Your health benefit plan provides coverage for prescription drugs and limited benefits for private home nursing which may be part of a palliative care plan. Long term care and home care services are not covered. If your plan includes a health spending account, many medical services are eligible as defined in the Income Tax Act. You may be able to arrange an additional leave of absence with your employer to look after a dying family member or close friend.
wCOVERAGE Personal insurance
Several kinds of individual policies may be purchased to help pay for palliative care. All policies will require you to submit evidence of good health and you must be covered under Prince Edward Island Medicare. Some insurers permit the conversion of some or all the benefits of a critical illness insurance (CII) policy to a long term care insurance (LTCI) policy without further evidence of good health if a CII claim has not already been approved.
• CII policies pay a lump sum to the policy owner or to the person they name to receive the benefit when the insured person is diagnosed with one of several life-altering conditions (which can include Alzheimer’s Disease, blindness, cancer, coronary artery bypass surgery, heart attack, loss of limbs, stroke, etc.) and survives the waiting period. Insurers offer different levels of coverage that include different health diagnoses.
• LTCI policies pay benefits when dependency occurs, as defined in the policy, although it is likely to have occurred prior to an insured person becoming palliative. Some LTCI policies provide benefits even when the insured person is not a resident in a long term care home. It is important to note that while many policies refer to physical dependency, the patient may be physically fine but dependent because of deteriorated mental ability.
• Personal health insurance policies provide coverage for many health-related expenses not covered by provincial medicare, such as drugs, semi-private hospital rooms, medical equipment and in-home nursing. You must be under a certain age to receive coverage, e.g. 60 or 70. This varies by insurer. Policy renewals are also age limited.
• Association plans for alumni, professional, trade association, union and some interest groups (e.g. an automobile association) typically offer a health and dental plan with broader coverage than personal health insurance policies and may require less stringent proof of good health.
• Disability insurance policies pay a monthly benefit, typically to age 65 or 70, which covers a portion of the insured person’s lost earnings.
• Life insurance can help settle a person’s final debts, including taxes.
COVERAGE Out-of-pocket expenses
• Depending on where the palliative patient lives, there may be personal costs, such as the cost of a semi-private hospital room, accommodation charges in long term care homes, home renovations, medical equipment or additional community resources (meals, personal support services or private nursing) that can be expensive. Please refer to other sections of this guide for more detail. Respite care – a break for the caregiver – may also cost you out of pocket.
HOMECARE
LONG TERM CARE
PALLIATIVE CARE
PRESCRIPTION DRUGS
TRAVEL EMERGENCY HEALTH
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PALLIATIVE CARE• The federal government pays up to six weeks
of compassionate care benefits under the Employment Insurance Act when someone has to be away from work temporarily to provide care or support to a family member who is gravely ill and who has a significant risk of death within 26 weeks. Other conditions apply, including a loss of at least 40% of your regular weekly earnings to care for that individual.
• Under the Income Tax Act, certain health insurance premiums and other eligible medical expenses may count towards a tax credit when total medical expenses exceed the lesser of $2,152 (2013) or 3% of your net income.
COSTS
• The Department of Health and Wellness pays for palliative care services once the patient has been assessed through the Home Care Program. Additional services may be needed, beyond what government will pay. Many communities have private supportive services such as day programs and respite care, available at extra cost.
FOR HELP
The province has produced a series of excellent brochures and booklets to help with many aspects of dying and managing grief for those who remain.
• Living Well with a Life-Limiting Illness helps determine your need and comfort with palliative care services.
• Care for the Dying is both instructive and sensitive to the needs of palliative care patients and loved ones.
• Help with the grieving process is available in Ten Things to Know About Grief.
• For those who have lost a loved one, The Healing Journey provides insight about the common expressions of grief, the healing process and when to get help.
• Children and adolescents have special needs and considerations, helpfully explained in Child and Teen Grief.
Contact information for the five provincial palliative care sites is here, as well as for the provincial integrated Palliative Care Program.
There are a number of private organizations with information helpful to those planning end of life care. The Canadian Hospice Palliative Care Association has published an Advance Care Planning Workbook as part of their Speak Up campaign.
The Hospice Palliative Care Association of PEI provides education and assistance, and a comprehensive directory of services.
The Canadian Virtual Hospice provides many resources, including its Ask a Professional feature. It includes information for Prince Edward Island.
The Victorian Order of Nurses supports caregiver-connect.ca which includes many helpful links by province.
The World Health Organization has created definitions of palliative care for adults and children.
Respite care – a break for the caregiver – may also cost
you out of pocket.
HOMECARE
LONG TERM CARE
PALLIATIVE CARE
PRESCRIPTION DRUGS
TRAVEL EMERGENCY HEALTH
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Overview
Canadians spend more on prescription drugs than any other health cost except hospitals and physicians.3 Access to prescription medicines is an important part of staying healthy, curing illness and preventing more serious harm. Coverage may be offered through different sources, but you should expect to pay at least some of the cost.
Provincial drug plans provide extensive, subsidized coverage for a defined list of drugs, called a formulary. More provinces now offer universal coverage for all residents, but sometimes coverage is just for certain groups, such as seniors, those on social assistance and those with high-cost drugs. If you’re employed or retired, your employer may provide a comprehensive drug plan for you and your family. However, plan designs, eligibility and costs vary widely and may be changed by the employer or insurer. Many workplaces do not provide coverage for part-time employees, contract employees or after retirement. Coverage is also available through personal health insurance plans or through alumni, professional, trade union or business associations. Your health and any existing drug use are typically used to determine the amount of insurance available to you or any exclusions that may apply.
COVERAGE Provincial government
• Prince Edward Island’s Pharmacare Program covers most of the cost of the prescription drugs on its formulary. There are eligibility criteria for both people and drug products as defined in legislation and regulations.
• Once annually, Pharmacare also covers the full cost of a pharmacist-delivered medication review:
◊ Basic medication review for those taking at least three eligible chronic-use medicines and who are enrolled in one of three programs: 1) Seniors Drug Cost Assistance Program, 2) Financial Assistance Program or 3) Private Nursing Home Program.
◊ Diabetes medication review for those who are taking at least one eligible diabetes medicine and who are enrolled in one of three programs: 1) Diabetes Program, 2) Financial Assistance Program or 3) Private Nursing Home Program.
• Other professional services are also paid by Pharmacare.
EligibilityTo be eligible for one or more of the 26 Pharmacare plans, you must be enrolled in the Hospital and Medical Services Plan (HMSP). Some programs require a specific application either from the patient or from a physician. These programs may be delivered through:
PRESCRIPTION DRUGS
3 Canadian Institute for Health Information, 2013. National Health Expenditure Trends, 1975-2013. See Table A.3.1.1-Part 2. Note that total expenditures for prescribed and non-prescribed drugs are greater than for physician spending.
Coverage may be offered through different sources,
but you should expect to pay at least some of the cost.
HOMECARE
LONG TERM CARE
PALLIATIVE CARE
PRESCRIPTION DRUGS
TRAVEL EMERGENCY HEALTH
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• Any community pharmacy or• Through hospitals:
◊ Erythropoietin◊ Rabies or
• Exclusively through the provincial pharmacy in Charlottetown (see pages 7 - 9 of the PEI Pharmacare Formulary):
◊ HIV/AIDS◊ Community mental health (may be further
distributed to five sites or physician offices)◊ Cystic fibrosis◊ Growth hormone◊ Hepatitis◊ Immunization◊ Institutional ◊ Intron A (interferon)◊ Nutrition◊ Phenylketonuria◊ Rheumatic fever◊ Transplant◊ Tuberculosis
Professional fees also vary considerably by program. Certain community programs have no fee (children in care, financial assistance, nursing home). There is generally no fee for all programs
delivered through the provincial pharmacy or through hospitals. Prescription quantities dispensed also vary by program.
Follow the links below for more information on each program:
• AIDS/HIV Drug Program
• Catastrophic Drug Program • Children in Care Drug Program • Community Mental Health Drug Program• Cystic Fibrosis Drug Program• Diabetes Drug Program• Erythropoietin Drug Program• Family Health Benefit Drug Program• Financial Assistance Drug Program• Growth Hormone Drug Program• Hepatitis Program• High Cost Drug Program• Home Oxygen Program• Institutional (Provincial Nursing Homes)/Private
Nursing Home Pharmacy Program4 • Intron A-Interferon Drug Program• Meningitis Drug Program• Nursing Home Drug Program• Nutrition Supplement Program• PKU Supplement Program
• Quit Smoking Drug Program• Rabies Vaccine Program• Rheumatic Fever Drug Program• Seniors’ Drug Cost Assistance Program• Sexually Transmitted Disease Drug Program• Transplant Anti-Rejection Drug Program• Tuberculosis Drug Program
PRESCRIPTION DRUGS
4 This program is noted under both names in the Prince Edward Island formulary, but detailed information is not available on the Pharmacare website.
HOMECARE
LONG TERM CARE
PALLIATIVE CARE
PRESCRIPTION DRUGS
TRAVEL EMERGENCY HEALTH
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COVERAGE Employer plans
• Drug plans offered through your workplace typically have broad formularies, low co-payments and cover everyone regardless of health status. However, expensive drugs may create serious financial hardship for some claimants because most plans do not limit your out-of-pocket expenses. Plan design, eligibility and cost-sharing are determined by the employer and are not guaranteed.
• For employer plans, enrolment is typically completed on or near your first day of work. A waiting period may apply. Most plans provide a drug card to eliminate claim forms and reduce your out-of-pocket costs at the time the drug is dispensed at the pharmacy.
• Your plan may be coordinated with that of your spouse to increase the total amount you will be reimbursed. Insurers have standardized coordination of benefit rules.
• If your employer plan terminates you may convert to a personal health insurance plan within 30 days.
COVERAGE Personal insurance
• Personal insurance plans provide top-up coverage for prescription drug expenses not covered by the provincial plan or your group or association coverage. Even if you are ineligible for coverage through the government or an employer (either your plan or your spouse’s), you may be able to apply for an individual plan or an association health insurance plan. Payment of the first premium after the insurer or association accepts your application automatically starts your coverage.
COVERAGE Out-of-pocket expenses
• If your insurance is limited or you have none, drug costs will be paid out of pocket. For selected products, drug manufacturers may offer patient assistance programs to qualified patients, typically where affordability is a problem. Certain physicians may be able to enrol qualified patients into experimental trial drug programs testing new medicines before they are approved by Health Canada.
• Private insurance plans may cover the cost of Pharmacare fees and co-pays and may provide coverage for drugs not on the PEI Pharmacare Formulary.
• Under the Income Tax Act, certain health insurance premiums and other eligible medical expenses may count towards a tax credit when total medical expenses exceed the lesser of $2,152 (2013) or 3% of your net income.
PRESCRIPTION DRUGS
Personal insurance plans provide top-up coverage for prescription
drug expenses not covered by the provincial plan or your group
or association coverage.
HOMECARE
LONG TERM CARE
PALLIATIVE CARE
PRESCRIPTION DRUGS
TRAVEL EMERGENCY HEALTH
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PRESCRIPTION DRUGS
COSTS
• Depending on which Pharmacare plan you qualify for, out-of-pocket costs can be significant. Patient costs can still be high under the new Catastrophic Drug Plan (effective October 1, 2013) even though there is a household cap on costs each year.
TOTAL PRE-TAX5 HOUSEHOLD INCOME RANGE
HOUSEHOLD CAP
$0 to $20,000 3%
$20,001 to $50,000 5%
$50,001 to $100,000 8%
Greater than $100,000 12%
Beneficiaries must arrange and pay for delivery of medications obtained through the provincial pharmacy.
• Most private drug plans require members to pay a share of premiums, plus an annual deductible and/or coinsurance fee for each claim. Most do not limit out-of-pocket payments, which can be an issue for claimants in poor health with high-cost therapy. Coordination of benefits between two plans — employee and spouse — may provide 100% coverage.
FOR HELP
Telephone Prince Edward Island Pharmacare at 902-368-4947 or toll-free at 877-577-3737. Telephone the provincial pharmacy at 902-368-4904.
For private insurance, contact your employer, insurer, financial advisor, association or union for administrative help. Your pharmacist may also help with questions on plan design and formulary eligibility.
HOMECARE
LONG TERM CARE
PALLIATIVE CARE
PRESCRIPTION DRUGS
TRAVEL EMERGENCY HEALTH
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Overview
Prince Edward Island’s Hospital and Medical Services Plan (HMSP) pays little and sometimes nothing for health services needed when outside Canada. Provincial governments recommend that you purchase travel health coverage for medically necessary emergency services when you are out of your province or outside Canada. The policy includes such things as a hospital stay, outpatient and physician services and assistance resulting from emergency treatment. Coverage will be limited to trips of a certain duration, e.g. 60, 180 or 365 days. There are limits to coverage and exclusions for pre-existing conditions including pregnancy. These limitations and exclusions may vary between individual and group plans.
COVERAGE Provincial government
• When travelling in Canada but outside Prince Edward Island and hospital and physician services are required, reciprocal billing arrangements exist among the provinces and so presenting a Health Card may ensure there are no out-of-pocket expenses. The exceptions relate to residents from the rest of Canada who need physician services in Quebec and residents of Quebec needing health (especially physician) services in other provinces. When travelling in Quebec or outside of Canada, a person may be required to pay for medical services and seek reimbursement later from the Prince Edward Island HSMP.
• If travelling outside of Canada, travellers are advised by the Department of Health and Wellness (Health PEI) buy travel emergency health insurance. Otherwise, it is likely they will have to pay for health services before care is provided and reimbursement by the HMSP is likely to take several months. Even then, the government warns that reimbursement will be for emergency services (accident or sudden illness) only and will be paid in Canadian funds at the same rate as would be paid in Prince Edward Island. The HMSP does not pay for drugs, dental, ambulance service or medical supplies. All claims must include a detailed invoice and proof of payment and be submitted within six months of hospital discharge.
• HMSP eligibility:◊ Prince Edward Island residents must register
with Health PEI to get a provincial Health Card. Full-time students at a university or other recognized educational institution are covered for emergency and sudden illness only. Students must notify Health PEI when leaving the province and update their student status on a yearly basis. HMSP coverage will lapse if one is not physically present in Prince Edward Island for at least six months plus one day, unless Health PEI waives this requirement. If one expects to be away for more than one month, they should notify Health PEI in advance to ensure they remain eligible. Most Canadians who are new residents of Prince Edward Island and former residents returning to Prince Edward Island must wait the balance of the month in which they arrive plus two more months after (re-)establishing residency to get coverage. Other conditions may apply.
Students must notify Health Prince Edward Island when leaving
the province and update their student status on a yearly basis.
TRAVEL EMERGENCY HEALTH
HOMECARE
LONG TERM CARE
PALLIATIVE CARE
PRESCRIPTION DRUGS
TRAVEL EMERGENCY HEALTH
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• Most group health plans cover reasonable and customary emergency hospital and medical expenses while you are travelling out of your home province. Many plans also offer supplemental emergency travel assistance services. Group benefit plans usually exclude costs for non-emergency or elective medical treatment or surgery performed outside Canada. They also limit the number of days of coverage. Many plans require that the travel assistance number be called as soon as possible after a medical emergency. Failure to do so may result in a reduction or decline in coverage of expenses. When in Canada, but outside one’s home province, reimbursement is typically limited to the difference between ward and semi-private hospital room rates and the underlying cost of a ward room is billed to that person’s provincial health plan. Physician services outside Canada are covered for emergency treatment but may be limited to the rate set by the provincial medical association. This could be less than the actual charges where the service is provided. One’s group plan may exclude pre-existing conditions or require health to be stable
for at least three months before a medical emergency would be eligible. It is important that travellers check their plan for coverage outside Canada before departing.
COVERAGE Personal insurance
• Coverage may be included with an individual health insurance policy but will typically have limits on the amount and duration of coverage and the age of the insured person. The insurer will require the insured person to call a travel assistance number to pre-authorize and manage treatment before any is given. Pre-existing health conditions are usually excluded or eligible only under defined conditions.
• Travel emergency health coverage may be available through gold or higher level credit cards or through the institutions that offer them. There are important differences between travel assistance and travel health or travel insurance plans which offer broader coverage and higher limits at higher cost. Individual plans will be restricted to people of certain ages, require proof of good health and contain exclusions or limitations for pre-existing conditions and certain services.
Travel health policies can also be purchased through an automobile association, travel agent or through brokers that can offer a wider variety of coverage through different insurers, including single or multiple trip and basic or comprehensive policies.
If you don’t have travel emergency health insurance, one can expect healthcare providers to demand payment before services are provided, especially in the United States. In worst-case scenarios, that can run tens or hundreds of thousands of dollars and it can also cost one the advantage of having a professional case manager to assist in understanding treatment options, trouble-shooting service issues, making decisions and returning safely to Canada.
TRAVEL EMERGENCY HEALTH
There are important differences between travel assistance and
travel medical or travel insurance plans which offer broader coverage
and higher limits at higher cost.
COVERAGE Employer plans
HOMECARE
LONG TERM CARE
PALLIATIVE CARE
PRESCRIPTION DRUGS
TRAVEL EMERGENCY HEALTH
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COVERAGE Out-of-pocket expenses
• Policies typically cost a few dollars a day depending on the age of the insured person, medical issues, features of the plan, the duration of the insured person’s trip and the insurer chosen. As with all insurance, buy from a highly rated insurer and use a reputable agent or broker. Inexpensive coverage may not be the most appropriate or offer the best value.
• Under the Income Tax Act, certain health insurance premiums and other eligible medical expenses may count towards a tax credit when total medical expenses exceed the lesser of $2,152 (2013) or 3% of one’s net income.
FOR HELP
To reach Health PEI, phone 902-838-0900 or toll-free at 321-5492. The provincial out-of-province coordinator is in Charlottetown, 902-368-6516. To appeal a decision regarding reimbursement for services received outside Canada, contact the Medical Affairs and Diagnostic Imaging in Charlottetown at 902-368-6516.
If one already has travel emergency health insurance, then their insurer or broker is their first point of contact. Many brokers maintain self-serve websites that provide comparative quotes after answering a few questions about one’s trip and their health.
To learn more about the industry and its partners, contact the Travel Health Insurance Association of Canada. The association maintains a consumer section on its website and recently published a short overview of travel insurance.
As well, the Canadian Life and Health Insurance Association has published a consumer booklet entitled A Guide to Travel Health Insurance.
TRAVEL EMERGENCY HEALTH
We gathered the information in this guide as of May 3, 2014. We’ve made a considerable effort to confirm that the information is accurate, but it may be incomplete or incorrect.
It’s important that you consult your own legal and tax advisors to review your personal situation. We also recommend you check your employer and personal insurance plans for details on your specific coverage.
Life’s brighter under the sun
We created this document for your information only. It’s important that you consult your own legal and tax advisors to review your personal situation. We also recommend you check your employer and personal insurance plans for details on your specific coverage.
The information in this guide was gathered from various authoritative sources as of May 3, 2014. We’ve made a considerable effort to confirm that this information is accurate, but in some cases it may be incomplete or incorrect. The information in this guide may not be current when you read it.
Sun Life Assurance Company of Canada is a member of the Sun Life Financial group of companies.© Sun Life Assurance Company of Canada, 2014.