Health Insurance Act

(Quebec)

The Health Insurance Act is administered by the Régie de l’assurance maladie du Québec (RAMQ) and protects residents of Quebec.

Services Covered in Quebec

Medical Services - The Medical Services Program is a universal program, which means that anyone covered by the Health Insurance Plan is eligible. The medical services covered by the Health Insurance Plan are those that are medically necessary and rendered by a general practitioner or a medical specialist. These services include: examinations; consultations, diagnostic services, therapeutic procedures, psychiatric treatments, surgery, radiology, anesthesia.

Dental Services - In hospitals, every insured person is entitled to certain oral surgery services in the event of trauma or an illness. These services are provided free of charge. Related examinations, local or general anesthesia and X-rays are also covered. Others services are covered for children under age 10 and persons who have been recipients of last-resort financial assistance for at least 12 consecutive months, and their dependants.

Persons entitled to covered dental services must present their valid Health Insurance Card to receive the services free of charge. Recipients of last-resort financial assistance and their dependants must also present their personal or family claim slip. In certain cases, for services provided by a denturist, authorization from a local employment centre is also needed.

Optometric Services - The Optometric Services Program is intended for: persons under the age of 18, persons aged 65 and over, persons aged 18 to 64 who have been recipients of last-resort financial assistance for at least 12 consecutive months, persons aged 60 to 64 who have received a spouse's allowance under the Old Age Security Act for at least 12 consecutive months and who, without this allowance, would be entitled to last-resort financial assistance benefits and visually impaired persons.

Devices that Compensate for Physical Deficiencies - This program is intended for persons insured under the Québec Health Insurance Plan who have a physical deficiency and meet the program's eligibility requirements. Persons who qualify for the plan and meet the conditions are entitled to:

• the purchase, adjustment, replacement, repair and, in certain cases, adaptation of walking aids, standing aids, locomotor assists and posture assists as well as their components, supplements and accessories;

• the purchase, adjustment, replacement and repair of orthotics and prosthetics.

Hearing Devices - Persons who qualify for the plan and meet the conditions are entitled to the purchase and replacement of a hearing aid and assistive listening devices.

Ostomy Appliances - The Ostomy Appliances Program is intended for persons insured under the Québec Health Insurance Plan who have undergone a permanent colostomy, ileostomy or urostomy of which the permanent nature is attested to by a medical certificate. If you are eligible for the Health Insurance Plan and meet all the requirements, you are entitled to an amount of $700, for each ostomy undergone, to cover most of the cost of the ostomy appliances you need. Every year thereafter, on the anniversary date of the operation, you will receive an amount of $700, for each ostomy, to cover the cost of replacing the ostomy appliances.

If you are a recipient of last-resort financial assistance, you will be reimbursed in full upon presentation of detailed invoices. It is therefore important to keep all proof of purchase. Persons accommodated in subsidized facilities are not entitled to the $700 amounts, since bags and other ostomy-related products are supplied by the facility free of charge.

External Breastforms - The External Breastforms Program is intended for all women insured under the Québec Health Insurance Plan who have undergone a total or radical mastectomy, and for women age 14 and over who have a total absence of breast formation, medically diagnosed as aplasia.

If you are eligible for the program and meet all the requirements, you are entitled, for each breast, to the amount of $200 to cover all or part of the costs related to the purchase of an external breastform. Every two years thereafter, on the anniversary date of the mastectomy or of the medical report, eligible women are entitled to an amount of $200 to cover the cost of replacing the breastform. If you are a recipient of last-resort financial assistance, you are entitled, upon presentation of proof of purchase, to a supplement (maximum $100, if the cost of the breastform exceeds $200) that will enable you to cover part or all of the actual purchase or replacement cost of the breastform.

Visual Devices - Persons eligible for the program are those whose visual acuity in each eye is less than 6/21, or whose visual field in each eye is less than 60° in the 180° and 90° meridians after correction by appropriate ophthalmic lenses (eyeglasses or contact lenses, but not special optical systems or additions of more than four dioptres).

Persons eligible for the program are entitled to obtain a visual device on loan, i.e. a reading, writing and/or mobility aid. Persons benefiting from the program are granted $210 for the cost of acquiring a guide dog, and $1,028 per year thereafter for the cost of looking after the dog.

Ocular Prostheses - If you are eligible for the program and meet the eligibility requirements, you are entitled, for each eye, to a reimbursement for the cost of purchasing or replacing an ocular prosthesis once per five-year period, and to a yearly allowance for the repair and maintenance of the prosthesis.

Financial Contribution and Assistance

Financial Contribution – Accommodated Adults

The financial contribution is the amount the government charges to adults who are accommodated in Québec healthcare facilities. To ascertain the amount of contribution, the room category and ability to pay are taken into account.

Financial Contribution – Intermediate Resources

Accommodation resources known as "intermediate resources" have been created in order to offer people who require supervision a residential environment as close as possible to a home environment and in which they receive the support and assistance they require. There are currently four main types of residences operated by intermediate resources: supervised apartments, rooming houses, reception homes and group homes. The contribution is payable as of the first day of accommodation and is calculated pro rata to the number of days of accommodation. The day of arrival is included but not the day of departure.

Financial Assistance for Domestic Help Services

Anyone aged 18 or older who are residents or temporary residents of Québec within the meaning of the Health Insurance Act are eligible for the program. However, people receiving compensation for domestic help services under a public plan (e.g. CSST, SAAQ, Veterans Affairs) or under a private insurance plan are not eligible for the program. The program's objectives are to help build a strong network of businesses providing domestic help services and to encourage people to use the services offered by these businesses.

The services covered are: light housekeeping work (such as laundering, vacuuming, dusting, cleaning), heavy housekeeping work (such a major cleaning jobs and clearing snow from the main access to the residence), cleaning clothes, preparing non-diet meals, shopping for groceries and running other errands. Some businesses do not offer all the above services.

Financial Assistance for Persons Infected with the Hepatitis C Virus

In May 1999 to offer financial assistance to all persons who were infected with the hepatitis C virus as a result of a blood transfusion or blood products received in Québec before January 1, 1986 or between July 2, 1990 and September 28, 1998.

Services Covered Outside Quebec

When travelling or when outside Québec temporarily: persons holding a valid Health Insurance Card can receive healthcare services covered by the Québec Health Insurance Plan. However, in most cases, the Régie de l'assurance maladie reimburses only part of the cost.

In order for these services to be covered, persons spending time outside Québec must fulfill certain conditions regarding the duration of their trip or temporary stay.

Private insurance: to avoid unfortunate consequences

Please bear in mind that the Régie usually cannot reimburse you in full and that the cost of healthcare services outside Québec is usually higher than in Québec. It is therefore essential to take out private travel insurance covering all or part of the costs not paid by the Régie. Obtaining insurance before leaving could spare you unfortunate financial consequences. If you receive healthcare outside Québec but don't have private insurance, you are responsible for the portion of the cost not reimbursed by the Régie.

When a Service is not Available in Québec: The Health Insurance Plan covers a wide range of essential medical services. However, in exceptional cases, some services may not be available in Québec. In such cases, and as a last resort, it is possible to request the Régie's authorization to receive healthcare outside Québec.

The Public Plan

The Public Prescription Drug Insurance Plan is a government insurance plan offering basic prescription drug coverage. It was set up in 1997 to cover all Quebeckers who have no access to private plan. The Public Prescription Drug Insurance Plan is intended for:

• persons aged 65 and over;

• recipients of last-resort financial assistance and other holders of a claim slip (carnet de réclamation);

• persons who do not have access to a private plan;

• children of persons covered by the public plan.

Persons under age 65 who have access to a private plan are not eligible for coverage under the public plan. They must take out coverage under the private plan to which they have access. Persons who turn 65 are automatically registered for the public plan, administered by the Régie. They therefore have no steps to take.

Many private insurers continue to offer prescription drug coverage to persons aged 65 and over who were already covered by such a plan. Two types of coverage may be available to them: basic coverage (at least equal to the coverage provided by the Régie) and supplemental coverage (in addition to the coverage provided by the Régie).

When persons who turn 65 remain eligible for a private plan offering basic prescription drug coverage, they have a choice to make. They may decide to be insured:

• only by the public plan, administered by the Régie;

• by the public plan (first payer) and by a private plan offering supplemental coverage (second payer); or

• only by a private plan offering at least the basic coverage.

Before deciding, they must ask their private insurer about the various options available and their cost.

Generally speaking, persons covered by the public plan must pay a premium, whether or not they purchase prescription drugs. The premium is collected every year by the Ministère du Revenu du Québec when income tax returns are filed. The amount of the annual premium varies from $0 to $585 per adult, depending on net family income. This amount is effective from July 1, 2009 to June 30, 2010.

Certain persons insured under the public plan don't pay a premium. These include:

• holders of a claim slip (carnet de réclamation) issued by the Ministère de l'Emploi et de la Solidarité sociale;

• persons age 65 or over receiving 94% to 100% of GIS;

• children of insured persons, If they are under age 18 or If they are 18 to 25, full-time students, without a spouse and live with their parents.

Insured persons pay only a portion of the cost of the drugs they purchase. This is called their contribution. The other portion is paid by the Régie. At the time of purchase, insured persons must inform the pharmacist that they are covered by the public plan and present their valid Health Insurance Card.

There is a maximum annual amount that insured persons may be required to pay for their drug purchases. This maximum amount, which has been set at $954 for all insured persons in Québec, includes the deductible and the co-insurance. Please note that this amount is lower for certain clienteles of the public plan.

Deductible

The deductible is a fixed amount that constitutes the first portion of the costs that insured persons must pay when obtaining insured drugs. For persons covered by the public plan, the deductible is a monthly amount that the person generally pays in full when making his or her first drug purchase during the month. For persons covered by a private plan, the deductible is generally a yearly amount. Certain private plans do not require the person to pay a deductible.

Co-Insurance

The co-insurance is the percentage (or portion) of the drug costs that insured persons must pay once they have paid the deductible. In other words, when a person's drug costs exceed the deductible, the person pays only a portion of the remainder.

Adjustment of Limits

The amounts for the premium, the deductible, the co-insurance and the maximum contribution are adjusted by the Régie de l’assurance maladie du Québec (RAMQ) on July 1 of each year. For private plans, the co-insurance amount must not be above 32%, and the annual maximum contribution must not exceed $954 for the period from July 1, 2009, to June 30, 2010.

To learn more about the Public Plan, visit the Group Insurance section of the SSQ Web site (www.ssq.ca). There, you can find answers to your questions about the plan by clicking on Basic Prescription Drug Insurance Plan: Answers to your Questions.

The table below shows the contributions in force from July 1, 2009, to June 30, 2010 for persons insured under the public plan.

Quebec City: 418-646-4636

Montreal: 514-864-3411

Elsewhere in Quebec (toll-free): 1-800-561-9749

For the deaf and hearing-impaired (TDD, telecommunications devices for the deaf):

Quebec City: 418-682-3939

Elsewhere in Quebec (toll-free): 1-800-361-3939

Web Site: www.ramq.gouv.qc.ca/index_en.shtml