In 2019, changes were introduced to the dispensing requirements for orthotics under the Public Service Health Care Plan (PSHCP). At that time, this information was shared with plan members who made claims for these products during the three previous years.
As of February 1, 2019, coverage for orthotics and repairs to orthotics are subject to a revised reasonable and customary amount of $550, reimbursed at 80 per cent for one pair of orthotics for each eligible dependent, per calendar year. The reasonable and customary amount for this benefit was previously $650.
Changes to the dispensing of custom orthotics were also implemented. Whereas previously, custom orthotics dispensed by a physician were eligible for reimbursement under the PSHCP, they must now be dispensed by one of the following specialists: podiatrist, chiropodist, pedorthist, orthotist, chiropractor, or certified orthotist (CO) or technologue professionnel (TP) in Quebec. This change ensures that custom orthotics are dispensed by trained specialists with the expertise to design high-quality orthotics that fit properly.
The modifications to the orthotics coverage were introduced to reduce Plan fraud and abuse. A spot audit on the orthotics benefit conducted by the Administration Authority, the organization that oversees Sun Life’s administration of the PSCHP, found a high degree of variability in orthotics pricing, suggesting potential abuse by certain service providers. The reasonable and customary amount was amended based on the findings of the spot audit, to help avoid excessive claims to the Plan and ensure plan members receive the most value for their money. Additionally, restricting who can dispense orthotics protects the Plan from incurring costs for expenses that may not be medically required.
The Administration Authority, which also handles PSHCP appeals, recently published an article on its website outlining this information after receiving several appeals from members who did not receive the initial communication. The Administration Authority has asked Federal Retirees to share this information with our members.
Please visit the PSHCP website for more information about the change.