PWGSC-TPSGC 481 - Public Service Health Care Plan (PSHCP) Relief Provision Application Form

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Public Service Health Care Plan (PSHCP) Relief Provision Application Form

Privacy Notice

Provision of the personal information is required pursuant to the Department of Public Works and Government Services Act, para. 7(1)(d) and s.13, for the following purposes: certify eligibility to the PSHCP Relief Provision and authorize deductions from your pension. Refusal to provide the requested information or the provision of incorrect information may result in loss of benefits and / or delays in processing your PSHCP Relief Provision Application. The personal information is protected and only used in accordance with the Privacy Act and as described in Personal Information Bank PWGSC PCU 703 Federal Government Employees, Pensioners and Survivors-Insurance Information. Under the Act, individuals have rights to request access to, and correction of their personal information, if erroneous or incomplete, and to make a complaint to the Privacy Commissioner of Canada.

Member Information

Are you in receipt of a monthly pension from a recognized pension plan at the date of this application?
Are you in receipt of a monthly pension from a recognized pension plan at the date of this application?
Are you in receipt of a Guaranteed Income Supplement (GIS) from Employment and Social Development Canada at the date of this application?
Are you in receipt of a Guaranteed Income Supplement (GIS) from Employment and Social Development Canada at the date of this application?
$
$

Spouse Information (If Applicable)

Are you in receipt of a monthly pensionfrom a recognized pension plan at the date of this application
Are you in receipt of a monthly pensionfrom a recognized pension plan at the date of this application?
Are you in receipt of a Guaranteed Income Supplement (GIS) from Employment and Social Development Canada at the date of this application?
Are you in receipt of a Guaranteed Income Supplement (GIS) from Employment and Social Development Canada at the date of this application?
$
$

Consent

I, the undersigned, have read the above Privacy Notice and consent to the collection and use and disclosure of my personal information, as described therein.

INFORMATION SHEET

Public Service Health Care Plan (PSHCP) Relief Provision Application Form

What percentage of contributions do retired members pay for their PSHCP coverage?

Retired members' percentage of contributions for Supplementary Coverage is currently 25% of the plan costs, excluding hospital coverage. The changes to the PSHCP cost sharing for retired members are:

  • Effective April 1, 2015, the plan cost percentage will rise to 31.25%;
  • Effective April 1, 2016, the percentage will increase to 37.5%;
  • Effective April 1, 2017 the percentage will be 43.75%; and
  • Effective April 1, 2018, the retired member share of the plan cost will have attained a 50% cost share ratio.

The rate will be adjusted annually after that date to maintain a 50:50 cost sharing ratio. Retired members who elect for coverage at levels 2 or 3 will continue to be responsible for 100% of the additional cost for the hospital coverage.

What is the PSHPC Relief Provision?

Retired members of the federal public service who are entitled to the PSHCP Relief Provision are eligible to retain the existing retired member / employer cost sharing ratio (25:75) for as long as they meet the criteria for the provision.

Who is eligible for the PSHCP Relief Provision?

To be eligible for the PSHCP Relief Provision you must be a retired member of the PSHCP with
Supplementary coverage (or have applied for PSHCP coverage) on or before March 31, 2015, and either:

  1. In receipt of a Guaranteed Income Supplement (GIS) benefit from Employment and Social Development Canada (ESDC); or
  2. Have a family net income (this includes a spouse income) as reported on line 236 of you and your spouse's previous taxable year Canada Revenue Agency (CRA) Notice of Assessment that is lower than the applicable GIS thresholds for an individual or couple.

The survivor of an eligible retired member who meets one of the above criteria is eligible to receive the PSHCP Relief Provision provided there is no break in PSHCP plan participation.

How do I apply?

Complete and sign the PSHCP Relief Provision Application Form and return it to your pension office. Please contact your pension office if you require assistance completing your application.

Do I need to re-apply for the PSHCP Relief Provision each year?

Approved applicants will be contacted next year and asked to again complete the new application form. That application form will provide your pension office with the authority to contact CRA and/or ESDC to obtain the necessary information to validate your continued participation in the PSHCP Relief Provision for both, next year and each year thereafter.

What if my income increases?

In the event you are no longer found to be eligible for the PSHCP Relief Provision through the annual
validation process, your PSHCP contribution rate will be adjusted to reflect the standard PSHCP retired member cost sharing ratio for the Supplementary coverage in the second month following your income validation.

Can I re-apply if my participation in the PSHCP Relief Provision was declined or terminated?

Yes, however, you will require to submit a new PSHCP Relief Provision Application Form.

Will my application be back-dated if my net income is re-assessed by CRA or my GIS application is retroactively approved?

No. PSHCP Relief Provision for those who meet the income thresholds of the program or who declare they are in receipt of GIS will only be effective the second month following your pension office's receipt of an application form.

PWGSC-TPSGC 481 E (2014-10)