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A N N U A L R E P O R T
2 0 1 9P S H C P . C A
Federal Public ServiceHealth Care PlanAdministration Authority
Letter from the Chairperson of the Board of Directors ........................................................................... 1
Letter from the Chief Executive Officer............................................................................................. 2
Highlights for 2019 ...................................................................................................................... 4
Strategic Objectives for 2019 ......................................................................................................... 5
Strategic Objectives and Organizational Goals for 2020 .......................................................................... 6
1 The Public Service Health Care Plan ........................................................................................... 7
1.1 The Federal Public Service Health Care Plan Administration Authority .............................................. 7
2 Governance of the PSHCP ........................................................................................................ 8
3 PSHCP Administration Authority Board of Directors .......................................................................... 9
3.1 Appeals Committee .........................................................................................................10
3.2 Audit and Finance Committee .............................................................................................10
3.3 Executive Committee .......................................................................................................11
3.4 Board of Directors - Assessment ...........................................................................................12
4 Organizational Structure ........................................................................................................14
5 Strategic Plan for 2019 ..........................................................................................................15
6 Operational Accomplishments in 2019 ........................................................................................16
6.1 Business Management .......................................................................................................16
6.1.1 Plan Renewal Support ................................................................................................16
6.1.2 Plan Directive Re-write ..............................................................................................16
6.1.3 Re-tendering of the PSHCP ..........................................................................................16
6.2 Audit and Evaluation ........................................................................................................16
6.2.1 Three-Year Risk-Based Audit Plan ..................................................................................16
6.2.2 Data Warehouse and Reporting Integrity Audit ..................................................................17
6.2.3 Vision Care and Laser Eye Surgery Spot Audit ....................................................................17
6.2.4 Privacy Audit – Sun Life Financial ..................................................................................17
6.3 Fraud ..........................................................................................................................18
6.4 Reporting, Research, and Analysis ........................................................................................19
6.4.1 Drug Benefit ...........................................................................................................19
6.4.2 Claims and Plan Membership .......................................................................................20
6.4.3 Reporting Initiatives..................................................................................................21
6.5 Appeals ........................................................................................................................21
6.6 Communications .............................................................................................................22
6.6.1 Plan Member Satisfaction Survey ..................................................................................22
6.6.2 Provider Survey .......................................................................................................23
6.6.3 PSHCP Administration Authority Website .........................................................................24
6.6.4 Communications Strategy ...........................................................................................24
ANNEX A – 2019 Board of Directors ..................................................................................................25
ANNEX B – 2019 Reporting Structure ................................................................................................28
ANNEX C – Governance and Stakeholders ..........................................................................................31
CONTENTS
2 0 1 9 A N N U A L R E P O R T
A WORD FROM YOUR CHAIRPERSONI am pleased to present the Administration Authority’s first Annual Report since I was appointed as Chairperson of the
Board of Directors in September 2019. Although my appointment with the organization is recent, I have had the privilege
of working closely with the PSHCP for many years and I am grateful for the opportunity to take on this new role.
The past year has seen some changes in the membership of the Board of Directors. I am sad to report that we are grieving
the untimely loss of Paul Morse, a long-time member of the Board of Directors. Although my time working alongside Paul
on the Board was short, I would like to recognize his many contributions to the PSHCP. We will miss his dedication and
wonderful sense of humour. Last year also marked the end of Jean-Claude Bouchard’s term as Chairman of the Board
of Directors. His accomplishments have positioned the Administration Authority for success and, on behalf of the Board,
I would like to take this opportunity to thank him for his strong leadership and guidance. I look forward to the
opportunity to continue to build on his legacy.
In 2019, the Administration Authority was heavily invested in two large projects which will help to shape the Plan for
years to come. The first pertains to the PSHCP’s contract with the current Plan Administrator which will reach its end
date in 2020. In recognition of the critical nature of this work, the Administration Authority has dedicated a significant
portion of its resources to support the retendering team involved in this complex, multi-year exercise. In addition, the
Administration Authority has worked closely over the past year with PSHCP stakeholders to support and prepare for Plan
renewal discussions. This included the coordination of plan costings and subsequent analysis, as well as a comparative
analysis of drug plan management solutions.
The Board of Directors has worked closely with the Administration Authority to review and analyze the rising costs of
our health care plan. When looking at the Plan experience in 2019, drugs make up approximately 70% of the expenses
to the Plan. In 2019, the PSHCP paid $962M for drugs, a 9% increase over the previous year. This is a trend that can be
expected to continue as new drugs are introduced each year. Claims for medical practitioner services have also increased
annually. In 2019, the PSHCP’s highest expenditures for claims for medical practitioners were for physiotherapy ($58.6M)
and psychology ($43.9M) services. These categories increased by 6.3% and 12%, respectively, over the previous year.
Considering the year-over-year growth of the Plan membership, the Administration Authority also expects these numbers
to increase in the years ahead. The Administration Authority remains committed to monitoring and reporting on these
costs to Plan stakeholders.
In closing, I would like to thank the staff of the Administration Authority and my fellow Board members for their
dedicated service in 2019. I have been thoroughly impressed by their ability to adapt, respond and innovate in a
fast-paced environment and I firmly believe that we are well-positioned to successfully meet our commitments for
2020 and beyond.
Caroline CurranChairperson, Board of Directors
PSHCP Administration Authority
LETTER FROM THE CHAIRPERSON OF THE BOARD OF DIRECTORS
2 0 1 9 A N N U A L R E P O R T 1
THE ONLY CONSTANT IS CHANGEIt seems like every year in my letter for the Annual Report there is a strong emphasis on the changes we have
experienced and how we have adapted. That is no accident, in that we have prioritized the development of certain
critical organizational strengths over the years that are central to our success such as our adaptability, flexibility
and nimbleness. These characteristics have allowed us to be responsive to our stakeholders and our members in an
ever-changing environment. At no time in our history have these qualities been more important than in 2019.
You will note this year that the author of the letter from the Chairperson is new to the organization, but not to our
milieu. I would like to welcome Caroline Curran as our new Chair appointed on September 1, 2019. In many ways,
it seems that the job description for her role was written with her in mind. Caroline brings many years of direct
experience with the Public Service Health Care Plan as a past Assistant Deputy Minister in the Pension and Benefits
Sector of the Treasury Board Secretariat. She has a vast knowledge of the inner workings of government, the Partners
Committee, the Administration Authority and the benefits industry. In a very short time, Caroline has had a positive
impact on the organization and I look forward to our collaboration for many years to come.
With the onboarding of Caroline, we said farewell to Jean-Claude Bouchard this year after 10 years as our Chair.
Jean-Claude’s departure marks the end of an era for the Administration Authority. Under his guidance and leadership,
the organization has blossomed into a high functioning entity that provides reliable and unbiased advice to Partners,
holds the Plan Administrator accountable for the conduct of their work in delivering on the requirements of the
Statement of Work and ensures that Plan members interests are respected. Jean-Claude fostered an attitude of
continuous improvement and he supported the growth and development of our organization and the natural evolution
of our role within the governance model of the PSHCP. Jean-Claude was instrumental in creating a strong focus on Board
Governance to evaluate the work of our Board and our organization. His good humour and his steady hand will be missed,
and I want to thank him for his invaluable contribution to the organization over the years.
The organization also experienced the departure of two senior staff team members in the late spring of 2019. As a
small organization, losing the expertise and leadership of two senior leaders is challenging. However, it also created an
opportunity to think about our organizational structure differently and to leverage the skills and abilities of some of our
other leaders resulting in expanded roles for our senior leadership team. In response to this challenge, we created two
new roles within our structure. The Chief Operating Officer role which we filled internally and the Chief Financial and
Compliance Office which we filled through an external recruiting process. These new roles of expanded responsibility
position the organization well for success today, and in the future.
Our challenges in 2019 were not limited to staffing and leadership changes on our Board of Directors. The demands of our
organization are twofold. On the one hand, we have a sophisticated planning process that identifies our core activities
and deliverables over a three year period. On the other hand, we have advisory, reporting and research activities in
respect of our obligations to the Partners Committee and of our plan management obligations. In some cases, these
deliverables are known and are incorporated into our planning process. However, in many cases, they are not known and
we have to adapt to the requirements while still delivering on our planned activities.
LETTER FROM THE CHIEF EXECUTIVE OFFICER
2 0 1 9 A N N U A L R E P O R T 2
This report reflects the nature of our planned activities and the breadth of the expertise of our team. We manage
appeals, conduct audits, provide plan reporting information, communicate with Plan members, develop and oversee
surveys, ensure the compliance of the Plan Administrator with the Statement of Work, evaluate Plan risk and conduct
research. These regular ongoing activities represent the majority of our work. We perform this work with precision and
efficiency and we are constantly looking for ways to improve our processes and the value of our products and services.
We have built a culture of competence together, and nowhere does that shine brighter than under the spotlight of
significant change.
As has become customary, we have also had to adapt to multiple initiatives to respond to the needs of our stakeholders.
We oversaw the conduct of three distinct plan costing exercises in support of Partners deliberations on the plan renewal
process. We also presented reports on the benchmarking study that was conducted in 2018 and we furthered our work
on drug plan data analytics with a comprehensive analysis of 2017 and 2018 drug plan data. We continue to support
the retendering of the plan by providing expertise and technical support to the process, accounting for hundreds of
person-hours over the course of the year.
As we look forward to 2020, I want to express how impressed I am with the staff of the Administration Authority.
They have demonstrated resilience and adaptability, a positive team spirit, a culture of continuous learning and personal
development, and a willingness to support the needs of the organization as required. These are the strengths of our
people, and the key to our success. I also want to thank our Board of Directors for their valued guidance and advice over
the year. Their support, experience and enthusiasm help to energize our organization while providing an important level
of oversight and organizational governance.
John LewisChief Executive Officer
PSHCP Administration Authority
32 0 1 9 A N N U A L R E P O R T
2019
GOVERNANCE Section 4
• Held an annual strategic planning meeting
that included presentations on Drug Data
Analytics and the impact of coverage of
cannabis on benefit plans.
• Completed an assessment of the Board’s
committees.
• Met with the Board of the Public Service
Alliance of Canada.
MANAGEMENT Section 6.1
• Provided technical support to the Partners
Committee in its renewal discussions.
• Facilitated plan change cost analysis for
the technical committee.
• Provided technical support to the Technical
Committee with regard to minor plan amendments.
• Collaborated with TBS in its re-tendering initiative.
AUDIT Section 6.2
• Completed a detailed risk assessment,
which informed the development of the
three-year Risk-Based Audit Plan.
• Supported an auditing firm and the Plan
Administrator to facilitate the Data
Warehouse and Reporting Integrity Audit.
• Conducted a vision care and laser eye surgery
spot audit.
• Conducted a Privacy audit of Sun Life.
REPORTING Section 6.4
• Analyzed cost savings related to Product
Listing Agreements.
• Performed extensive reviews of the Drug Benefits.
• Conducted analysis to estimate potential
cost-shifting of changes introduced to
provincial/territorial health care plans.
• Conducted research related to
emerging medications.
APPEALS Section 6.5
• Received 501 appeals in 2019, a 2.5%
decrease over 2018.
• 62.1% of appeals were related to the level of
benefit or a decision by the Plan Administrator,
37.9% concerned coverage or eligibility issues.
• 9% of appeals were upheld, 89.9% were
denied, and 1.1% were deferred pending
additional investigation.
COMMUNICATIONS Section 6.6
• Conducted a second online survey on the uptake
and satisfaction with Sun Life’s Digital Services
that were introduced in April 2018.
• Uploaded 11 monthly articles to the PSHCP
Administration Authority’s website.
• Updated the PSHCP Communications Strategy.
• Provided oversight of the Plan Member
Satisfaction Survey and the Provider
Satisfaction Survey.
HIGHLIGHTS 2019
STRATEGIC OBJECTIVES FOR 2019
PLAN STEWARDSHIP
To be recognized for reliable contract stewardship
• Provide program oversight and compliance.
• Develop a three-year Operations Plan and a corresponding budget.
• Develop a Plan Risk Assessment.
• Produce a three-year Risk-Based Audit Plan.
• Produce an Annual Report and a Compliance Report.
STAKEHOLDER RELATIONSHIPS
To strengthen key relationships
• Launch the fourth online Plan member survey and conduct an analysis of the data.
• Produce quarterly and annual reports for the Partners Committee.
• Oversee the completion of the Supplementary and Comprehensive member surveys.
• Review and update the Communications Strategy.
EXPERTISE
To be recognized as a knowledge leader on the Plan and related industry trends
• Work with a drug data analytics firm to conduct a comparative transaction-level data analysis of drug claims for the policy years 2017 and 2018.
• Provide technical support to the retendering initiative.
• Provide an updated version of the Plan Directive.
GOVERNANCE
To be recognized for excellence in governance and management
• Hold an annual strategic planning session.
• Conducted an assessment of the board performances.
2 0 1 9 A N N U A L R E P O R T 5
STRATEGIC OBJECTIVES AND ORGANIZATIONAL GOALS FOR 2020
PLAN STEWARDSHIP
To be recognized for reliable contract stewardship
• Provide program oversight and compliance.
• Develop a three-year Operations Plan and a corresponding budget.
• Develop a Plan Risk Assessment and produce a three-year Risk-Based Audit Plan.
• Produce an Annual Report.
STAKEHOLDER RELATIONSHIPS
To strengthen key relationships
• Produce quarterly reports for the Partners Committee.
• Review the Communications Strategy.
• Launch an online survey of the membership and conduct the data analysis.
EXPERTISE
To be recognized as a knowledge leader on the Plan and related industry trends
• Provide technical support to the PSHCP retendering initiative.
• Provide technical support to the PSHCP renewal initiative.
• Complete the rewrite of the Plan Directive.
GOVERNANCE
To be recognized for excellence in governance and management
• Provide support to the Partners Committee.
• Hold an annual strategic planning session.
• Complete an assessment of the Board of Directors.
2 0 1 9 A N N U A L R E P O R T 6
The Public Service Health Care Plan (PSHCP) is the largest private health care plan in Canada, providing benefits to
over 701,000 Plan members and their dependants, totalling a Plan participant population of 1.5 million. The PSHCP
is sponsored by the Government of Canada. Its members include federal public service employees, parliamentarians,
federal judges, and pensioners receiving an ongoing pension benefit based on their service in one of these capacities.
Members of the Canadian Armed Forces and Royal Canadian Mounted Police may also join the Plan in order to obtain
coverage for their eligible dependants.
Its purpose is to reimburse Plan participants for the reasonable and customary costs they have incurred for eligible
services and products as described in the Plan Directive. Reimbursement is considered after they have taken advantage
of the benefits provided by their provincial or territorial health insurance plan and/or other applicable private plans.
The PSHCP also provides coverage to members who reside outside of Canada for basic health care services equivalent,
as much as possible, to the services covered by provincial and territorial health care plans.
1.1 THE FEDERAL PUBLIC SERVICE HEALTH CARE PLAN ADMINISTRATION AUTHORITYThe Federal Public Service Health Care Plan Administration Authority (the Administration Authority) is a corporation
without share capital whose mandate is to oversee the administration of the PSHCP. The Administration Authority
ensures that the Plan Administrator (Sun Life Assurance Company of Canada) delivers benefits efficiently and effectively
to PSHCP members in accordance with the Plan provisions.
The Administration Authority is accountable to the Partners Committee. It has several operational and reporting
responsibilities which include, but are not limited to:
• Ensuring that service standards outlined in the Contract are met;
• Conducting audits and evaluations regarding the payment of PSHCP benefits;
• Processing appeals submitted by Plan members;
• Communicating with Plan members about their benefits;
• Providing accurate, comprehensive, and up-to-date information on Plan performance;
• Providing direction to Sun Life on the interpretation of Plan provisions; and
• Reporting incidents of fraud.
THE PUBLIC SERVICE HEALTH CARE PLAN
1
2 0 1 9 A N N U A L R E P O R T 7
The Administrative Services Only Contract (hereinafter referred to as the Contract) established between the Project
Authority (TBS), the Contract Authority (Public Services and Procurement Canada), and the Plan Administrator sets
out the scope and the service delivery objectives of the PSHCP Contract. Legal authority to establish and modify the
provisions of the Plan is achieved through negotiations with the Treasury Board of Canada, which is formally accountable
to Parliament for the investment of public funds and the performance of the PSHCP.
In 2007, the governance structure for the PSHCP was revised to create the Partners Committee and the Federal Public
Service Health Care Plan Administration Authority. An illustration of the Plan’s governance is available under Annex C.
The Partners Committee focuses on Plan design and cost management. It is composed of seven members: three
representatives of the employer appointed by the President of the Treasury Board of Canada, three employee
representatives appointed by the bargaining agents of the National Joint Council, and one pensioner representative
appointed by the President of Treasury Board Canada on the recommendation of the National Joint Council. You may visit
the Administration Authority’s website at pshcp.ca to view the current members serving on the Partners Committee.
The Administration Authority was established under Letters Patent, issued pursuant to subsection 7.2(1) of the Financial
Administration Act. Its mandate is to ensure that the Plan Administrator complies with the Contract and administers
PSHCP benefits efficiently and effectively as per the Plan’s provisions. It also includes the adjudication of appeals from
members regarding benefit entitlement or a coverage issue.
GOVERNANCE OF THE PSHCP
2
2 0 1 9 A N N U A L R E P O R T 8
The Administration Authority is governed by a Board of ten directors. One director is appointed by the President of
the Treasury Board of Canada, on the recommendation of the National Joint Council of the Public Service, for the
role of chairperson. Another director is appointed by the President of the Treasury Board of Canada, again on the
recommendation of the National Joint Council, who, in the opinion of the President, best represents the pensioners.
Four directors are appointed by the President of the Treasury Board of Canada, and four directors are appointed by that
portion of the National Joint Council of the Public Service that represents the employees. Directors are appointed for
terms of one to four years, and are eligible for reappointment after satisfactory completion of their terms. A listing of
all directors serving on the board of the Administration Authority as of December 31, 2019, is available under Annex A.
The Board of Directors is responsible for overseeing the management of the Administration Authority and is involved
in the following activities:
• Approving the strategic direction and the triennial Operations Plan;
• Ensuring that potential threats and principal risks are identified and managed;
• Approving major decisions that relate to the Plan;
• Monitoring the performance of the Chief Executive Officer;
• Supporting the Chief Executive Officer in the development and implementation of organizational policies;
• Overseeing the financial management of the Administration Authority; and
• Approving management succession plans, which include the appointment, training, compensation, and
monitoring of the Chief Executive Officer.
In performing these oversight duties, the Board of Directors is supported by three committees composed of Board
members selected by the Chairperson.
The Board of Directors and staff of the Administration Authority would like to acknowledge Paul Morse’s dedication
and leadership over the many years that he served on the Board until his untimely passing in November 2019.
The Board of Directors and staff of the Administration Authority would also like to thank Jean-Claude Bouchard for
his contribution as Chairperson of the Board for the past ten years. Jean-Claude’s term lapsed on August 31, 2019,
and his departure from the organization marks the end of an era at the Administration Authority. Under his guidance
and leadership, the organization transformed itself into a high functioning organization that provides reliable and
unbiased advice to stakeholders and actively holds the Plan Administrator to account for their performance in delivering
on the requirements of the Statement of Work. Jean-Claude fostered an attitude of continuous improvement and he
supported the growth and development of our organization and the natural evolution of our role within the governance
model of the PSHCP. Jean-Claude was instrumental in creating a strong governance model for our organization to evaluate
the work of our Board and assess their performance on an ongoing basis.
PSHCP ADMINISTRATION AUTHORITY BOARD OF DIRECTORS
3
2 0 1 9 A N N U A L R E P O R T 9
3.1 APPEALS COMMITTEECHAIR | Paul Morse (June 2011 to November 2019)
MEMBERSHIP | Five directors
STAFF SUPPORT | Director, Appeals and Member Services; Appeals Analyst
COMMITTEE MANDATE | The primary function of the Appeals Committee is to consider, when requested by a Plan
member, the appeal of a decision of the Plan Administrator regarding a specific benefit entitlement and/or a decision
relating to a member’s coverage.
The Appeals Committee is mandated to review and make recommendations on all appeals submitted by members and/or
their representatives, consistent with the provisions of the Plan Directive and to report to the Board of Directors of the
Administration Authority.
KEY ACCOMPLISHMENTS OF 2019
• Held four meetings throughout the year and heard 366 appeals;
• Reduced the number of appeals in inventory by 46% compared to 2018; and
• Continued to identify sections of the Plan Directive that could be considered confusing or easily misinterpreted
by Plan members. Examples of these areas include the following:
o The prescribing power of nurse practitioners;
o The lack of clarity regarding the application of the physician’s clause;
o The requirement for insulin pumps to be prescribed by a physician associated with a recognized
centre for the treatment of diabetes at a university in Canada.
3.2 AUDIT AND FINANCE COMMITTEECHAIR | Wendy Loschiuk (April 2019 to present)
MEMBERSHIP | Five directors
STAFF SUPPORT | Chief Operating Officer
COMMITTEE MANDATE | The Audit and Finance Committee assesses the adequacy of risk management processes and
makes recommendations to the Board of Directors based on their findings. The Committee reviews the Administration
Authority’s internal control system and its processes for complying with legal requirements and regulations. It helps the
Board oversee the organization’s financial risks, the reliability of its financial reporting and the quality of its internal
controls. The Committee governs the organization’s annual external audit and ensures the implementation of an effective
Plan Risk Assessment framework and audit plan. It is also responsible for ensuring that financial statements and reports
are provided to the Partners Committee on a timely basis. The Committee reviews the requirements of the Contract to
ensure that audits and monitoring programs are implemented on a regular basis. The Committee also provides guidance
to the Chief Executive Officer on all accounting-related matters and makes recommendations to the Board of Directors
for approval.
KEY ACCOMPLISHMENTS OF 2019
General
• Clarified the Audit and Finance Committee quorum requirements; and
• Recommended a site visit of the Plan Administrator’s Operations for new directors.
102 0 1 9 A N N U A L R E P O R T
Finance
• Recommended the appointment of auditors for the 2019 fiscal year;
• Coordinated an external audit of the Administration Authority’s financial statements, thereby gaining
assurance that the accounting information was accurate;
• Conducted a post-financial audit meeting with the Administration Authority’s external auditors to review
the audited financial statements; and
• Oversaw the organization’s financial reporting (financial statements, variance reports & budget).
Risk Assessment and Auditing
• Reviewed the annual Risk Assessment outcomes and validated that the risks to the Plan were effectively
addressed in the three-year Risk-Based Audit Plan;
• Reviewed the Vision Care and Laser Eye Surgery Targeted Spot Audit report and requested that a number of
modifications be made. The report was subsequently recommended for approval to the Board of Directors;
• Endorsed the work plan for the 2019 Privacy Audit of Sun Life; and
• Stayed abreast of the delays for the Data Warehouse and Reporting Integrity Audit and conveyed the
Committee’s concerns to the Board of Directors.
3.3 EXECUTIVE COMMITTEECHAIR | Jean-Claude Bouchard (2017 – August 2019)
Caroline Curran (September 2019 to present)
MEMBERSHIP | Seven directors
STAFF SUPPORT | Chief Executive Officer
COMMITTEE MANDATE | The Executive Committee ensures the effectiveness of the Administration Authority’s
governance structure, identifies functions that may require strengthening, and makes recommendations to the Board of
Directors based on its findings. It also ensures that the combination of skills and experience of each Director aligns with
the strategic direction of the Administration Authority, manages the Board’s Code of Conduct, develops their training and
qualification requirements, and conducts performance reviews that assess their strengths and weaknesses.
With regard to communications, the Executive Committee supports the Administration Authority’s Board of Directors
in the oversight of effective communications to Plan members and stakeholders including the Partners Committee.
This includes identifying the appropriate tools and messages for external communications and the development of an
outreach strategy. The Committee reports to the Board of Directors on its assessment of communications and makes
recommendations on future initiatives to address any gaps, inconsistencies or inadequacies.
The Executive Committee is also responsible for the oversight of human resources issues. Its main functions in this
area are:
• Assisting the Board in fulfilling its responsibilities in the management of human resources by promoting
leadership, continuity and competence at the senior management levels of the Administration Authority; and
• Reviewing and making recommendations in the areas of organizational structuring, hiring, staff relations,
succession planning, staff training and development, performance management and executive and staff
compensation. It also supports the Board of Directors and its Chairperson on matters relating to CEO
performance and compensation.
112 0 1 9 A N N U A L R E P O R T
KEY ACCOMPLISHMENTS OF 2019
Governance
• Continued the outreach efforts that were deployed in 2018. In addition to regular attendance at the Partners
Committee and the Technical Committee meetings, the Administration Authority met with the Board of the
Public Service Alliance of Canada to present the results of the 2015-2016 Data Analytics as well as the findings
of the 2018 Plan Member Satisfaction Survey;
• Reviewed the recommendations of the 2019 Board Assessment and reviewed the Institute on Governance’s
proposal for the 2020 Board Assessment; and
• Reviewed and approved the ‘Request for Board Appointments’ documents that were sent to the appropriate
appointing bodies to fill vacancies on the Board.
Communications
• Updated the PSHCP Administration Authority’s Communications Strategy to reflect the ownership of member
communications, the improved nimbleness of the communications function, the Administration Authority’s
expanded reach in communications, and a review of best practices in benefits communications;
• Reviewed the 2018 Annual Report and the 2018 Compliance Report;
• Reviewed the results of the 2018 Benchmarking Study; and
• Provided oversight of the website survey that was implemented in November 2019.
Human Resources
• Supported the Administration Authority in its efforts to recruit three individuals: a Chief Financial and
Compliance Officer, a Director of Compliance and a Director of Communications;
• Approved the addition of an Employee Assistance Program to the suite of benefits offered to the staff;
• Reviewed the updated HR policy suite; and
• Evaluated and recommended the approval of the CEO’s mid-year and year-end performance appraisal.
3.4 BOARD OF DIRECTORS - ASSESSMENTThe Administration Authority’s Board of Directors has an established Board assessment policy that includes Board,
committee and peer assessment components, with one component being completed each year over a three-year period.
The policy called for an interview-based assessment of the Board’s committees in 2018-2019 as listed above (Executive,
Appeals, Audit and Finance). This review, conducted by the Institute on Governance, involved preliminary meetings and
planning sessions, a document review, an online survey and a series of one-on-one interviews. The documents reviewed
included the Letters Patent, committee Terms of Reference and a sample of committee annual reports and records of
decisions. The data collection included the results of the online survey and discussions with Board Directors and members
of the senior management team, including the Chief Executive Officer.
The IOG’s review revealed that the Administration Authority’s committee governance is strong and that the focus
should be on moving from very good to great. Among the many strengths identified by interviewees are clear
mandates, supported by annual work plans, calendars and reports, as well as good participation and consensus-driven
decision-making on recommendations to the Board. Other strengths identified include effective staff and information
support to committees, committee membership driven by both representation and expertise, and strong chairmanship
of committees.
122 0 1 9 A N N U A L R E P O R T
Areas of improvement were also highlighted. They include continued difficulties with attendance, the opportunity to
improve committee orientation, distinguishing committee and Board discussions, and ensuring active Board approval
of appeal decisions.
Governance is a journey and strong Boards are committed to continuous improvement. It is in this spirit that the
Institute on Governance offered the following recommendations:
• Address attendance and associated quorum challenges;
• Consider modifying the approval process of appeals; and
• Consider implementing a short, mandatory briefing for board members new to any particular committee.
132 0 1 9 A N N U A L R E P O R T
The Administration Authority prides itself on the capacity and competence of its personnel.
The staffing complement at the Administration Authority in 2019 comprised 13 full-time employees with expertise in
numerous fields including finance, management, audit, compliance, communications, and group benefits administration.
In order to meet its strategic objectives, the Administration Authority’s work is divided into three main functional areas:
BUSINESS MANAGEMENT
This function includes the management and oversight of the organization’s strategic and operational processes,
its internal financial and human resources management activities, and the overall monitoring of Sun Life’s compliance
within the parameters of the Contract.
OPERATIONS AND AUDIT MANAGEMENT
This function includes the management of Contract compliance of the Plan. Staff within the function oversee the
audit program of the PSHCP, the implementation of the Risk-Based Audit Plan, risk analysis and management, fraud
investigations and prevention, research, analysis, and reporting.
COMMUNICATIONS AND MEMBER SERVICES
This function coordinates the planning and execution of communications initiatives across a range of audiences, manages
the appeals process, provides oversight of claims processing and call centre-related issues, addresses member inquiries,
and facilitates the correct interpretation of Plan provisions.
ORGANIZATIONAL STRUCTURE
4
Health Economics &Reporting Analyst
Chief Executive Officer
Chief OperatingOfficer
Chief Financial andCompliance Officer
Director of Appeals and
Member Services
Director, Communications
Director, Program Compliance
CommunicationsAdvisor
Sr. ProgramCompliance Analyst
AppealsAnalyst
Office Manager
Director, Reporting, Research and Risk
Management
Senior Director, Communicationsand Member Services
ProgramCompliance
Analyst
2 0 1 9 A N N U A L R E P O R T 14
In consideration of ever-changing circumstances within the public sphere and the group benefits industry,
the Administration Authority strives to be flexible and responsive to the needs of the Partners Committee, the Project
Authority, Plan members, and the Plan Administrator. The Administration Authority updates the Strategic Plan on an
annual basis and aligns its Operations Plan accordingly.
The Strategic Plan includes the Administration Authority’s vision, mission, and strategic objectives for the year. Specific
deliverables and initiatives are identified by the organization in order to achieve these goals. The Administration
Authority then submits the Strategic Plan to the Partners Committee for approval, as required under the Letters Patent.
STRATEGIC PLAN FOR 2019
5
VISION
Serving the Partners Committee and Plan members by adding value to the administration of the Public Service Health Care Plan through superior knowledge, experience, and innovation.
MISSION
To ensure that benefits and services to Plan members and their covered dependants, as defined in the PSHCP documentation, are delivered in a manner that ensures the effective and efficient administration of the Plan.
STRATEGIC OBJECTIVES
PLAN
STEWARDSHIP
To be recognized for reliable contract
stewardship.
STAKEHOLDER RELATIONSHIPS
To strengthen key relationships.
EXPERTISE AND INNOVATION
To be recognized as a knowledge leader on the Plan and related
industry trends.
GOVERNANCE
To be recognized for excellence
in governance and management.
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6.1 BUSINESS MANAGEMENT6.1.1 Plan Renewal Support
At the request of the Partners Committee, the Administration Authority prepared summaries and analysis to support
the Plan renewal activities. This included capturing and conveying detailed Plan costing requests originating from the
Partners Committee for Sun Life to cost and execute via three detailed work orders. Following an extensive review
and analysis of the initial costing reports, the Administration Authority liaised with Sun Life to clarify the methodology
employed and the responses provided. A final report was then delivered to the Partners Committee. This significant
undertaking was completed over a six-month period and the final costing reports were delivered in September 2019.
The Administration Authority subsequently received a request to support the Partners Committee’s Renewal Committee
by conducting a comparative analysis of the drug plan management solutions proposed by the Plan Administrator and
those recommended by the consulting firm who conducted data analytics on the PSHCP experience for drugs and medical
supplies. The procedural and financial implications resulting from the significant variances between the two sets of
solutions were presented to the Renewal Committee in the fall of 2019.
6.1.2 Plan Directive Re-write
The Administration Authority continued its efforts to modernize the Plan Directive. The intent is to remedy a number of
concerns and issues that have arisen over time with the provisions within the document. This initiative is a collaboration
between the Administration Authority and the entity responsible for providing technical support to the Partners
Committee known as the Technical Committee. Both parties have worked together throughout 2019 to identify, review,
suggest and agree upon minor plan amendments. This work will continue throughout 2020 with the intent of having a
Plan Directive completed once negotiations have concluded.
6.1.3 Re-tendering of the PSHCP
Throughout 2019, the Administration Authority continued to work in partnership with TBS to develop the Request for
Proposal (RFP) for the next PSHCP Contract. This involved participation in more than 10 working groups including Claims,
Reporting, Communications, Positive Enrolment, Provider Registration and Audit. It is expected that the Administration
Authority’s efforts in the re-tendering of the PSHCP will continue throughout 2020 to support the finalization of the RFP
and participate in the bid evaluation process.
6.2 AUDIT AND EVALUATION 6.2.1 Three-Year Risk-Based Audit Plan
Each year, the Administration Authority conducts a Plan Risk Assessment which helps to inform a three-year Risk-Based
Audit Plan. The plan establishes the nature of the audits that are to be performed over this three-year period and
estimates their timing, scale, and scope. Once complete, the plan is tabled with TBS and the Partners Committee before
being shared with Sun Life. This advance planning allows for the allocation of sufficient resources and ensures that
Sun Life and its subcontractors are in a position to support the audits. It also enables the Administration Authority to
carry out the audit plan in an orderly fashion.
When conducting a Plan Risk Assessment, the Administration Authority considers a wide variety of factors. Elements such
as contractual requirements, year-over-year trends, and volumes of claims by benefit category are assessed to identify
financial risk. Knowledge obtained from industry research and Plan experience allows for a more qualitative assessment
OPERATIONAL ACCOMPLISHMENTS IN 2019
6
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of risk. The results of previously conducted audits are also taken into consideration to develop a comprehensive
evaluation of the Plan risks.
The ensuing three-year audit plan includes audits of financial operations, privacy, reporting services, mechanisms
supporting claims adjudication as well as specific benefits such as psychology, drugs and physiotherapy.
6.2.2 Data Warehouse and Reporting Integrity Audit
The Data Warehouse and Reporting Integrity Audit, originally scheduled for the fall of 2018, has been delayed beyond
2019 to address data security concerns expressed by Sun Life. The Administration Authority engaged the Canadian
Industrial Security Directorate (CISD) at Public Services and Procurement Canada (PSPC) who issued letters of reference
based on their evaluation of the auditing firm’s data transport, storage and destruction protocols. The endorsement from
CISD was not sufficient to address Sun Life’s data security concerns and, throughout 2019, the Administration Authority
continued to work diligently with Sun Life and the auditing firm to establish means by which this audit could proceed.
There have been several meetings between the parties involved to find a workable solution to conduct the audit in the
second quarter of 2020.
6.2.3 Vision Care and Laser Eye Surgery Spot Audit
In 2019, the Administration Authority conducted a spot audit of Vision Care and Laser Eye Surgery claims. This audit was
previously included in the 2018 – 2020 Risk-Based Audit Plan.
The spot audit reviewed claims for services incurred during the 2017 calendar year. It was conducted to obtain reasonable
assurance that Sun Life has complied with the criteria established by the provisions of the Contract for the PSHCP.
Based on the PSHCP Risk Assessment, the Administration Authority determined that Vision Care Benefit claims are an
area of high risk to the Plan for the following reasons:
• Significant dollar value of paid claims in prior years coupled with significant year-over-year growth for
each service;
• Introduction of the laser eye surgery benefit in 2014, a category of claims that has yet to be audited;
• Online purchases could be made for non-covered individuals and submitted to the PSHCP for reimbursement.
The audit involved the review of a random and risk-based sample of claims to ensure submitted expenses were
substantiated with the required documentation (receipts, referrals, completed and signed claim forms) and that
reimbursements were made in accordance with the provisions of the Plan.
The results of the audit were mostly favourable. A list of the findings was discussed with Sun Life who clarified that,
for part of the procedural errors, the requirements were not yet introduced as a part of the verification process.
Based on the nature of the errors and responses from Sun Life, a further audit is not currently necessary.
6.2.4 Privacy Audit – Sun Life
The current contract between Sun Life and the Government of Canada stipulates that a privacy audit of the Contractor
must be conducted on an annual basis. Sun Life and Millennium 1 Solutions (M1S) were previously audited in 2014.
That exercise was followed by privacy audits of Allianz Global Assistance (Allianz) in 2015 and TELUS Health (TELUS)
in 2016. In 2018, the Administration Authority conducted a Privacy Audit Framework to determine whether Sun Life,
TELUS and Allianz had implemented the recommendations of the previous audits. The 2019 Privacy Audit was exclusive
to Sun Life and its sub-contractor, M1S, and the audit was centred on the following criteria:
• The accuracy of the Sun Life Privacy Operations Document; Ref. Statement of Work (SOW) 4.13.2;
• The management of personally identifiable information and personal health information of PSHCP members
throughout its lifecycle to ensure that it is consistent with the requirements of the Privacy Act and its
associated regulations, policies, directives and standards; Ref. SOW 4.13.1;
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• Privacy breach reporting mechanisms at Sun Life and M1S; Ref. SOW 4.13.3;
• Quarterly privacy reports produced by Sun Life; Ref. SOW 4.13.4, and;
• The administrative, technical and physical controls that are in place to ensure that personally identifiable
information and personal health information of Plan members are protected and secured; Ref. SOW 4.13.1,
4.13.8 – 4.13.10.
The auditor concluded that Sun Life and M1S are compliant with Article 4.13 of the SOW. Each organization has
developed and implemented a robust privacy management framework to support the management and monitoring of
privacy practices. They have the systems and procedures in place to identify, monitor and mitigate privacy risks related
to the PSHCP, and they continue to refine and improve their privacy processes to ensure they remain compliant with the
requirements of the SOW.
Sun Life and M1S have demonstrated that they have the tools in place to ensure that privacy and the protection of
personal information remains a priority of all employees. Sun Life and M1S employees receive mandatory privacy and
security training annually. They are familiar with the relevant privacy legislation and their contractual requirements in
the management of personal information and health information of PSHCP members. Privacy training is regularly updated
and privacy awareness is promoted across the organizations though regular reminders, bulletins, events and the Intranet.
Sun Life is consistent in its reporting of privacy incidents to the Administration Authority through its Quarterly Privacy
Report. While Sun Life shows the resolution of an incident in the report, remedial measures such as changes to policies or
processes to prevent similar incidents from occurring are not included. A recommendation has been made to include any
remedial measures to policies or processes as a result of a privacy incident. This modification will assist in improving
Sun Life’s report to the Administration Authority by sharing information about lessons learned through the corrective
actions taken to avoid potential privacy breaches.
6.3 FRAUD Fraud Management is a critical component in the oversight of a publicly funded health care benefit plan, particularly one
as large as the PSHCP. It ensures that the incidence of fraud and misuse of the Plan is minimized and that suspected fraud
cases are investigated and managed effectively.
In collaboration with Sun Life and TBS, the Administration Authority ensures effective and efficient fraud case
management and resolution. The Administration Authority evaluates case information, determines risk, and prepares
case summaries with recommendations for review by TBS.
As part of its 2015 anti-fraud strengthening strategy, Sun Life enhanced its data-mining system by refining the criteria
links and triggers in order to reduce the number of unfounded fraud alerts generated and to more accurately detect
instances of fraud and abuse. In addition, Sun Life programmed the system to prioritize PSHCP cases. It was expected
that these enhancements would lead to an increase in the number of suspected fraud cases identified within the Plan.
While the number of suspected fraud cases reported to the Administration Authority in 2019 is higher than the volumes
reported in previous years, nearly all cases were identified through channels other than Sun Life’s data-mining system.
On April 1st, 2018, Sun Life introduced digital services for the PSHCP which allowed members to submit claims for certain
non-drug expenses through the Sun Life Plan Member website or the my Sun Life Mobile application. As part of the
implementation of digital services, Sun Life introduced additional audit controls to verify that these claims are valid and
consistent with Plan provisions.
Since the introduction of digital services, nearly 60% of the suspected fraud cases reported to the Administration
Authority involved the submission of false digital claims and included Paper Claims that had gone undetected.
On August 25th, 2019, Sun Life’s Digital Audit Redesign project changed its approach from pre-payment audits to
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post-payment audits to improve member experience and further their Fraud Risk Management deterrence techniques.
With this new approach, members are notified when they are required to upload the supporting documents for their
claims. The impact of these changes remains to be assessed.
Despite 2019 being the year with most suspected fraud cases detected, the number of cases identified remains lower
than expected for a health care plan as large as the PSHCP. In order to enhance their fraud detection capability,
in December 2018 Sun Life implemented machine learning technology across their block of business, including the PSHCP.
This new technology leverages Sun Life’s vast amount of data (e.g. claims information, social media, public websites,
tips from clients, geolocation, etc.) to better anticipate fraud, however, it is still in the very early stages of
implementation. Sun Life has also been working on implementing dual-factor authentication and monitoring changes
in member’s profiles (e.g. bank account changes) to prevent submission and payment of false claims in cases where
a member’s identity has been compromised.
The Administration Authority continues to monitor results closely to ensure that anti-fraud strategies and enhancements
made to Sun Life’s data-mining tool and fraud detection capabilities effectively address PSHCP risks. In order to
efficiently manage and resolve suspected fraud cases, the Administration Authority is also collaborating with TBS to
develop a policy framework for the management of false claims.
6.4 REPORTING, RESEARCH, AND ANALYSIS Under its reporting, research and analysis functions, the Administration Authority conducts periodic and ad hoc analyses,
and oversees reporting initiatives to support the evolution of the information needs of its stakeholders.
To meet the requirements listed in the Letters Patent, the Administration Authority developed a reporting structure
(see Annex B) whereby reports are provided to the Partners Committee on a monthly, quarterly, annual and an as-needed
basis. The organization also developed a delivery management plan that enables TBS to evaluate the performance of
the Administration Authority against predetermined accountabilities. Discrete research projects and ad hoc analysis
initiatives are also undertaken at the request of the Board of Directors and the Partners Committee.
6.4.1 Drug Benefit
In 2019, the Administration Authority regularly conducted research related to emerging medications ranging from
traditional drugs to specialty drugs and biosimilars (previously referred to as Subsequent Entry Biologics drugs or SEBs).
Biosimilars are similar but not identical versions of the reference originator biologic. Research was conducted on new
specialty drugs for the treatment of cancer to better understand the therapeutic value of these drugs and their potential
cost implications for the PSHCP. The research focused on Vitrakvi, Idhifa and Lorbrena. The estimated cost of these new
drugs ranges from $266,000 - $520,000 per year.1
Research related to orphan drugs for the treatment of rare diseases, such as Ultomiris and Translarna, was also
performed in order to assess the potential impact of these ultra-high cost drugs. This research included the potential
PSHCP population that could be affected by these rare diseases and the annual cost associated with treatments.
Research also included, where applicable, a review of the recommendations provided by the Canadian Agency for
Drugs and Technologies in Health (CADTH) for these drugs. CADTH provides evidence-based information about the
cost-effectiveness of drugs to provincial and territorial drug plans.
In 2019, the PSHCP entered into Product Listing Agreements (PLAs) secured by the Plan Administrator, which resulted
in cost savings for a number of high-cost drugs. Since the nature of the agreements is confidential, the Administration
Authority does not have details regarding the drugs subject to these agreements, with the exception of Remicade,
which is the second highest paid drug for the PSHCP. As Remicade is included in the PLAs secured by the Plan
Administrator, the Administration Authority performed an analysis and assessment of the cost savings resulting from
this agreement.
1 TELUS Health. The Drug Pipeline: What’s coming for private plans. Spring 2019.
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This exercise included an evaluation of the Plan experience to ensure that it reflected the discounted amounts across
all provinces and territories.
Additional research and analysis were completed to estimate the potential cost-shifting implications of certain changes
introduced to provincial and territorial health insurance plans. These changes included the redesign of OHIP+ in April
2019 to no longer offer drug coverage to individuals age 24 years or younger with private drug coverage, as well as the
introduction of biosimilar switching programs in British Columbia and Alberta, which require patients to transition to
less expensive biosimilars if they wish to continue to receive coverage under the public drug plan. In British Columbia,
a phased approach is being implemented in 2019-2020 that will apply to a number of biologic drugs, namely Remicade,
Enbrel and Lantus. Alberta’s biosimilar initiative will be implemented in July 2020 and will apply to the same three drugs
covered by British Columbia’s biosimilar initiative as well as Neulasta, Neupogen and Copaxone. The Administration
Authority’s cost impact analysis also included an assessment of upcoming changes to Alberta’s Seniors Drug Benefit
Program, which will no longer cover non-senior dependants of covered seniors as of March 2020.
In 2019, the Administration Authority performed extensive reviews of many additional aspects of the PSHCP Drug Benefit
claims experience for the 2018 calendar year. Included in these reviews was in-depth analysis of key drug therapeutic
classes presenting the most notable change, the top 20 drugs by paid amount, the fill rate of brand versus generic drugs,
the average paid amount by province and territory, and many other statistics used to evaluate the changes and trends in
the PSHCP drug claims experience. Much of this analysis was presented to the Board of Directors throughout 2019 and will
continue to inform the Board on an annual basis.
The table below lists the top ten drugs paid by the Plan in 2019. The Plan experience was calculated by combining all
of the claimed dosage forms for each drug.
2019 TOP TEN DRUGS BY PAID AMOUNT
Rank Drug Name Disease Name
1 HUMIRA * Rheumatoid Arthritis
2 REMICADE * Rheumatoid Arthritis
3 STELARA * Psoriasis / Psoriatic Arthritis
4 ROSUVASTATIN High Cholesterol
5 EYLEA * Macular Degeneration
6 SHINGRIX* Shingles
7 ATORVASTATIN High Cholesterol
8 XOLAIR * Asthma / Urticaria
9 REVLIMID * Cancer
10 XOLAIR * Asthma / Urticaria
*Specialty or biologic drug
6.4.2 Claims and Plan Membership
In 2019, the Administration Authority produced its annual key performance indicators (KPI) report that outlines the
change in Plan expenditures, the annual cost per member and the relative change by benefit and member groups over
the last three calendar years. Staff presented this information to the Board of Directors and will continue to do so on
an annual basis. Along with the KPI report, summary Plan tables were distributed to the Board. These tables include
high-level Plan experience by benefit and Plan type (e.g. Supplementary and Comprehensive), and more detailed data
for the top two benefits, namely prescription drugs and medical practitioners.
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Throughout 2019, ongoing paid claims analyses were performed and outcomes were presented to the Board of Directors
on a monthly basis. Paid amounts for claims, fees and taxes were evaluated and reported against the same period in the
previous year. The change in cost per member was assessed and cumulative results were updated. Standard reporting
results were compared against ad hoc data to validate the accuracy and consistency of the reports.
A review of Plan expenditures, Plan membership data and an in-depth analysis of certain PSHCP benefits was performed
and presented to the Board of Directors on a quarterly basis. This review included: average Plan cost per member,
distribution of paid amount by member group, paid amount growth trends for all benefit categories, and a more in-depth
analysis of the drug and medical practitioner benefits.
The Administration Authority calculated the taxable benefit amount for PSHCP members who reside in Quebec and
participate in the Veterans Affairs Canada (VAC) group. The Government of Canada performs this task for employees and
pensioners, however, they cannot complete this task for the VAC group because contributions are remitted directly to
Sun Life rather than pension or salary deductions. Therefore, the Administration Authority has been completing this
task for a number of years. Based on the data extract provided by Sun Life, the Administration Authority performed
calculations per the number of months a member was covered under the new and previous contribution rate, taking into
account changes in their coverage (i.e. single, family, employee, pensioner, etc.). The final report was provided to VAC in
January 2019.
6.4.3 Reporting Initiatives
On the direction of the Partners Committee, the Administration Authority undertook a comprehensive Plan data
analytics initiative for the PSHCP prescription drug and medical supplies benefits. To this end, a data analytics firm
was engaged to assist in the process by examining transactional-level drug and medical supplies claims data paid within
the PSHCP experience. The first set of data analytics focused on claims paid from 2015 and 2016. As a result of this
initiative, a number of findings and opportunities were identified as a means of mitigating future Plan risks enhancing
the benefits plan.
The data analytics initiative also identified a number of adjudication practices requiring further investigation.
After an extensive review process with the data analytics firm and the Plan Administrator, the Administration Authority
documented its findings and prepared recommendations for changes in adjudication practices where these do not align
with the PSHCP provisions. These were shared with the Plan Administrator and TBS in 2019, and it is expected that the
work addressing these adjudication issues will continue in 2020.
At the end of 2018, the Administration Authority initiated a second, scaled-down version of data analytics. This second
phase review continued in 2019 and focused on the PSHCP experience for the 2017 and 2018 benefit years with the intent
to gain insight into any new emerging concerns, to identify trends evident in the most current data and to understand
whether the key strategic areas of opportunity previously identified are growing, lessening or staying stable. This set of
analytics confirmed the relevance of the opportunities identified in the first phase of the data analytics initiative.
The results of the second phase of data analytics were presented to the Board of Directors at their annual strategic
meeting held in May 2019 and subsequently to the Partners Committee in July 2019. The Administration Authority was
then tasked with undertaking further analysis and industry research related to the implementation of the identified
drug plan management opportunities. The results of the Administration Authority’s analysis for each of the potential
opportunities were presented to the Partners Committee to support their Plan renewal discussions.
6.5 APPEALS The Administration Authority’s mandate includes the management of the appeals process. This avenue is available to all
Plan members who do not agree with a decision regarding their claim or coverage and wish to have their file reviewed.
Upon receipt of an appeal, the organization thoroughly reviews the circumstances outlined in the member’s appeal.
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It then gathers and analyzes pertinent information provided by relevant governmental departments and/or the
Plan Administrator. Appeals are then presented to the Appeals Committee for review and recommendation.
The decisions of the Appeals Committee to uphold or deny an appeal are ratified by the Board of Directors of
the Administration Authority and decisions are considered final. Appeals Committee meetings are scheduled on a
quarterly basis.
The Administration Authority received 501 appeals in 2019, a 2.5% decrease over 2018. The Appeals Committee reviewed
366 appeals in 2019, a 22% decrease compared to the 469 cases heard in 2018. The decrease is attributable to the timing
of appeal submissions and a temporary resourcing shortfall. Of the appeals presented in 2019, 62.1% were related to
either a decision rendered by the Plan Administrator or to the level of benefits offered under the Plan. The remaining
37.9% of appeals concerned coverage (i.e. refund of contributions, retroactive coverage, etc.). Of the 366 appeals heard
by the Appeals Committee in 2019, 9% were upheld, 89.9% were denied and 1.1% were deferred pending additional
investigation. The slight decrease in approval rates when compared to 2018 can be attributed to a drop in cases
related to administrative errors occurring at the Canadian Armed Forces units/Orderly Rooms. Such cases were handled
administratively as they did not need to be presented to the Appeals Committee.
The most common types of appeals reviewed in 2019 are listed below in order of frequency:
• Requests for a refund of contributions (117 appeals);
• Late claims (29 appeals);
• Requests for backdated coverage (18 appeals);
• Psychology by a non-eligible practitioner (17 appeals);
• Acupuncture by a non-physician (11 appeals);
• Viscosupplementation device (11 appeals);
• Wheelchair/Scooter/Walker purchased prior to the 60-month timeframe (7 appeals).
A total of 90 cases submitted to the Administration Authority did not constitute appeals and were handled without being
presented to the Appeals Committee. This represents a 51.4% decrease compared to 2018; a year in which a significant
number of cases held in abeyance were closed following a decision rendered by the Partners Committee regarding the
eligibility criteria of certain procedures under the Plan’s provision for physician services. Approximately 42% of the cases
handled in 2019 stemmed from administrative errors made by representatives from various employee departments,
the pension office, and the Plan Administrator. These cases represent situations where the member’s grievance was
warranted and should have been corrected by either the Plan Administrator or the appropriate department or pension
office without involvement from the Administration Authority.
At year-end, 35 appeals were pending a decision from the Partners Committee in relation to the Plan’s provision for
physician services and laboratory services. The procedures awaiting a decision included: breast augmentation surgery
related to gender reassignment, laser optical biometry, Oncotype-DX breast cancer genomic testing and photodynamic
therapy for cancerous and pre-cancerous skin lesions. Additional research papers to be presented to the Partners
Committee for consideration will be finalized in 2020. These are in relation to the following procedures: bariatric surgery,
coblation turbinate reduction and non-invasive prenatal testing.
6.6 COMMUNICATIONS 6.6.1 Plan Member Satisfaction Survey
As part of its obligations as the PSHCP Plan Administrator under the Contract, Sun Life must conduct member satisfaction
surveys. Therefore, surveys were conducted in 2013, 2017, and 2019. The objective of the surveys is to gauge the Plan
members’ overall satisfaction with Sun Life services such as the Plan member website, the my Sun Life Mobile app,
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the call centre, claims processing, and communication services. The surveys also evaluate member satisfaction with
Allianz Global Assistance, a Sun Life subcontractor that manages claims processing and inquiries for members residing
or travelling abroad.
In the summer of 2013, Sun Life conducted the first survey of members with Supplementary coverage using a paper
mail-back methodology to randomly selected members. Responses to the survey were substantial with over 8,000
members recording levels of satisfaction across several service features. At the time, members with Comprehensive
coverage were not surveyed due to methodological issues associated with capturing online survey responses.
In 2017, Sun Life circulated the second PSHCP Plan Member Satisfaction Survey for members with Supplementary
coverage. It adopted a multi-channel methodology of both print mail-back as well as electronic online surveys to
maximize reach to members and to achieve higher response rates. Sun Life also launched the first electronic survey
for members with Comprehensive coverage. To allow for comparison between Supplementary and Comprehensive member
satisfaction, many of the same lines of questioning were repeated. For the Comprehensive Plan Member Satisfaction Survey,
new questions on member satisfaction with claim experience and call centre services provided by Allianz were added.
In 2019, the same multi-channel methodology (print mail-back as well as electronic) was employed to ensure that
responses were adequately representative of both the active employee and pensioner memberships. The questions for
members with Supplementary coverage were adapted to account for the implementation of Sun Life’s digital services
which were made available to members in April 2018. The new questions gauged member satisfaction and uptake with
digital claims submission, the Provider Search tool, the Drug Look-Up tool, and the Click to Chat web service.
OBJECTIVE OF THE 2019 PLAN MEMBER SATISFACTION SURVEY
The objective of the 2019 Plan Member Satisfaction Survey was to gauge Plan members’ overall satisfaction with Sun Life
and Allianz Global Assistance’s services and ascertain how members perceive the quality of services that they provide.
The PSHCP Member Satisfaction Survey was sent to over 20,700 randomly selected Plan members residing in Canada and
4,000 residing out-of-country. Half of the surveys were distributed electronically while the other half was distributed as a
paper-based hard copy. The survey was sent to a proportionate amount of members with Supplementary and to the entire
community of members with Comprehensive coverage.
As the survey was conducted in the fall of 2019, the results will be made available in January 2020.
6.6.2 Provider Survey
Approximately 9,000 pharmacy providers are registered with the PSHCP and are authorized to submit electronic claims
directly to the PSHCP on behalf of Plan members. In collaboration with the pharmacy benefit manager, TELUS Health,
a third-party provider conducted a telephone survey of 267 randomly selected pharmacists to provide feedback on their
experience with the systems and services offered for the PSHCP.
The survey found that respondents were generally satisfied with the services offered by TELUS Health for the PSHCP.
More than a third (38%) of the surveyed population stated that they were highly satisfied with TELUS, an increase of
3% from 2016. While the majority of pharmacists feel TELUS Health is comparable to other pharmacy benefit managers on
the market, perceptions of TELUS Health continue to improve. Satisfaction with the claims submission process continues
to receive the highest satisfaction score across all service areas evaluated. Although satisfaction with audit services once
again received the lowest satisfaction score across all touchpoints measured, certain elements within the category have
improved. For example, of the pharmacists who have completed a PSHCP audit, 50% still feel that the frequency of audits
has an impact on their day-to-day operations. However, this represents an 11% decrease over 2016.
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6.6.3 PSHCP Administration Authority Website
The PSHCP Administration Authority website is a medium used by the Administration Authority to transmit new and
important information to PSHCP members. In addition to the static content which remains posted to the website,
informative articles are published monthly to ensure that members are aware of the benefits to which they may be
eligible under the PSHCP. Topics elaborated upon in 2019 monthly articles included the voluntary cessation of coverage,
delisted health care providers, coordination of benefits, and the assignment of benefits among others.
The website also houses the bi-annual editions of the PSHCP Bulletin which provide a more comprehensive account of
the changes and intricacies of PSHCP provisions. Bulletins are co-developed by the Administration Authority, Sun Life,
and TBS. Topics in the two bulletins that were published in 2019 included, among others, the new contribution rates for
retired members as of April 2019, updates on Sun Life’s digital services, coverage for dependant children, and coverage
for retired members.
Finally, the Administration Authority uses its website as a means to interact with PSHCP members by way of an annual
survey. The website survey was originally conducted to gain a better understanding of Plan membership demographics,
the members’ intent while visiting the website, their opinion of the website and how they thought it could be improved.
Following the launch of Sun Life’s Digital Services in April 2018, the website survey was adapted to assess member uptake
and satisfaction with the newly implemented services. New questions were added to the survey which probed on member
satisfaction with services such as the Drug Look-Up tool, the Click to Chat service, the Provider Search tool, and digital
claims submission. The information acquired from the survey will be compared to the findings of future surveys to assess
the evolution of member satisfaction with the digital services available to them. Results from the 2019 Digital Services
Website Survey will be available in January 2020.
6.6.4 Communications Strategy
The Administration Authority recognizes that various priorities may emerge as the PSHCP and its administration continue
to evolve. The organization is committed to reviewing its communications strategy on an annual basis in compliance
with the responsibilities that are outlined in the Letters Patent. An in-depth assessment of the strategy is completed
periodically to ensure that it is still relevant to the PSHCP.
The Administration Authority tabled its revised communications strategy with the Partners Committee in Q2 of 2019.
The document highlights the organization’s current communications priorities and establishes objectives that will help
the Administration Authority achieve its long-term communications goals.
In order for this communications strategy and plan to materialize, the PSHCP Administration Authority recommended the
creation of a PSHCP Communications Advisory Committee. The committee’s objective would be to facilitate exchanges
and the dissemination of information. This would allow for a better understanding of collective issues in order to choose
the best strategies and action plans to address them. The committee would also ensure that communication to Plan
members is consistent by providing integrated and strategic communications. The purpose of the committee would be
to inform, educate, consult, and involve stakeholders in order to improve communication to Plan members.
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ANNEX A2019 Board of Directors
CHAIRPERSON OF THE BOARD OF DIRECTORSCAROLINE CURRAN
Chair since: 2019 | Current term: September 1, 2019 to August 31, 2023
Committee: Chair of the Executive Committee
Caroline Curran has held a series of executive-level positions since her public service career began in 1995. Notably, at the Treasury Board of Canada Secretariat, she has held the positions of Special Advisor to the Chief Human Resources Officer responsible for the wellness and mental health portfolios, Assistant Deputy Minister of the Pensions and Benefits Sector and the Executive Director of the Human Resources Division. From 2015 until her retirement in 2019 Caroline was the co-chair of the Joint Task Force on Mental Health Technical Committee, comprised of representatives of both bargaining agents and the Employer.
DIRECTORSSETH SAZANT
Director since 2018 | Current term: July 10, 2018 to July 9, 2021
Committee: Serves on the Audit and Finance Committee
Seth Sazant joined the Public Service Alliance of Canada in 2006. Since that time, he has been working in the negotiations section and is currently working as a Negotiator/Pension and Benefits Officer. Much of his work has been focused on extended health and dental plans.
TAMMY LABELLE
Director since 2016 | Current term: August 1, 2017 to July 31, 2020
Committee: Serves on the Appeals and the Executive Committees
Tammy Labelle has a demonstrated track record in managing and leading various files in the area of public service benefits and compensation. In addition to her Board duties, she serves as Chief Information Officer, Digital Services Branch at Public Services and Procurement Canada.
PIERRETTE BOYER
Director since 2013 | Current term: September 16, 2016 to September 16, 2019
Committees: Serves on the Appeals and the Executive Committees
Pierrette Boyer retired from the public service in September 2013. Her last position was Chief of Staff and Special Advisor to the Assistant Deputy Minister of the Pensions and Benefits Group at the Treasury Board Secretariat. During her public service career, Pierrette developed and implemented pension policies and programs as well as pensions and benefits communication products.
2019 BOARD OF DIRECTORS
AANNEX
2 0 1 9 A N N U A L R E P O R T 26
ROBERT HART
Director since 2019 | Current term: June 28, 2019 to June 27, 2023
Robert Hart has spent most of his career working in the group benefits industry both in the private and public sectors. Most recently he was Expert Advisor, Pensions and Benefits Sector, Treasury Board Secretariat of Canada where he had oversight responsibilities with respect to the Canadian Armed Forces Group Insurance Plan (SISIP) and the RCMP Group Life and Disability Insurance Plans. Prior to that, he worked for a number of years with SISIP Financial, Canadian Forces Morale and Welfare Services. He has served on several interdepartmental policy teams as well as the RCMP Insurance Advisory Committee.
JACQUES LAMBERT
Director since 2017 | Current term: August 1, 2017 to July 31, 2020
Committee: Serves on the Appeals and the Audit and Finance Committees
Before retiring in 2009, Jacques Lambert served in the public service for 41 years with several departments, including Veterans Affairs Canada and the Ministry of Employment and Immigration. For more than 15 years, Jacques has been actively involved in national committees and on management boards.
WENDY LOSCHIUK
Director since 2018 | Current term: April 9, 2018 to April 8, 2021
Committee: Chairs the Audit and Finance Committee and serves on the Executive Committee
Wendy Loschiuk retired from the Office of the Auditor General of Canada (OAG) in 2015 where she was an Assistant Auditor General. After joining the public service in 1979, Wendy started her career with the Department of National Defence, reviewing programs and spending, before moving to the Treasury Board of Canada Secretariat and the OAG.
EDWARD (EDDIE) GILLIS
Director since 2012 | Current term: September 12, 2018 to September 11, 2021
Committee: Serves on the Executive Committee
Edward (Eddie) Gillis has spent 25 years in the labour relations field. He is the Chief Operating Officer and Executive Secretary of the Professional Institute of the Public Service of Canada where he leads the Institute’s management team and staff compliment.
JOHN GORDON
Director since 2012 | Current term: May 1, 2016 to April 30, 2020
Committees: Serves on the Appeals, Audit and Finance, and Executive Committees
John Gordon has worked for the public service since 1974 and has held numerous positions within the Public Service Alliance of Canada, including that of National President from 2006 to 2012.
ACKNOWLEDGMENTS
The Board of Directors and staff would like to thank Dominic Laporte for his contribution to the Administration Authority during his term on the Board from 2016 to 2019. The Board would especially like to acknowledge Paul Morse’s contribution and his dedication to the organization during the five terms he served on the Board of Directors since 2006.
272 0 1 9 A N N U A L R E P O R T
ANNEX B2019 Reporting Structure
Exec
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– A
nnua
l Del
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able
s
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ANNEX CGovernance and Stakeholders
Governance and Stakeholders
President of theTreasury Board
Pensions and Benefits Sector, Treasury Board Secretariat
As appropriate
As appropriate
PSHCP PolicyDevelopment
PSHCPOperations
Administration Authority Board
of Directors
As appropriate
OperationsCommittee
AuditSub-Committee
Plan MemberSub-Committee
FinanceSub-Committee
Audit and FinanceCommittee
ExecutiveCommittee
AppealsCommittee
Technical PolicyCommittee
Partners Committee
National JointCouncil
Senior ContractManagement Committee
TBS RepER RepBA RepNeutral (and AA Rep)Pensioner RepPWGSC (CA) RepSLF Rep
ANNEXC
2 0 1 9 A N N U A L R E P O R T 32
P S H C P . C A