Quels sont les principes de base ?

What are the basic criteria?

Since January 1st, 1997, everyone in Quebec has access to drug insurance coverage meeting the basic criteria of the BPDIP (Basic Prescription Drug Insurance Plan), either through a private drug insurance plan offered by an insurer or an employee benefits administrator, or through the coverage of the public drug insurance plan¹.

When a person under the age of 65 is eligible for a private plan, they are required to join the plan (sections 15 and 15.1), along with their spouse and children (section 18), unless they are covered by another private plan. The plan cannot make a distinction based on age, gender or health condition (section 37), and the insurer cannot refuse a member (section 42).

At the age of 65, the person is automatically registered with the BPDIP without having to take any steps. However, if this person is eligible for a private insurance plan, they can also choose to keep it and cancel the public coverage, provided that the plan meets the minimum criteria of the BPDIP. In addition, the insurer or plan administrator of such a plan, must accept the membership of every eligible person 65 years of age or over who applies for membership.

The plan cannot offer protection in the event of an accident, illness or disability unless it offers drug coverage compliant with the rules of the BPDIP (section 38 for insurers; section 39 for employee benefit plan administrators).

The private plan must offer coverage meeting the minimum criteria provided for by the Act, failing which the member is required to join the public plan and pay the premium of the public plan through their tax return.

[1] Pooling participants (the Participants) are group insurance insurers or employee benefit plan administrators in the private sector (these plans are also known as administrative services only or ASO plans

What are the plan’s compliance criteria?

To comply, the private plan must offer the following minimum conditions:

• Cover all prescription drugs on the RAMQ list (section 60), as well as drugs payable under the “Exception Patient” program (section 78), without any limitation on the amount (section 8);
• Be at least as generous as the public plan (section 78) for the deductible (section 26), the copay share (section 12) and the member’s maximum contribution (section 13). In 2021, these figures are : $261, copay share of 35% or less and $1,161 ; and
• Be subject to pooling (section 43) according to the conditions enacted and published by the QDIPC after consultation with pooling participants.

What are the main rules for pooling?

Principle: All groups covering members residing in Quebec and benefiting from a group insurance plan providing drug coverage are subject to pooling.

Among the criteria enacted by the QDIPC, the group is subject to the following:

• Thresholds, Terms and conditions, which vary depending on group size;
• The rules stipulated in the compliance certificate;
• Audits and routine checks;
• Only Quebec certificates are pooled, but the group size is determined on the basis of all Canadian certificates;
• Group size is determined on the basis of the rules and fairness criteria mentioned in QDIPCinfo – Group Size;
• Multi-employer groups are subject to prior approvals;
• A Quebec certificate can be defined as a member whose residential address and whose payroll deductions are in Quebec;
• Pooling comes before any other form of coverage, reinsurance, stop-loss insurance or any other form of pooling; and
• Pooling data are provided and certified by the insurer for insured groups and by the benefits plan administrator for uninsured groups.

Exception to this principle

Employers without a place of business in Quebec who offer their employees a group plan are not required to offer coverage that includes prescription drugs which meets the minimum criteria of the BPDIP. When the plan in place does not meet the minimum criteria of the BPDIP, these employees residing in Quebec must join the public plan unless they have access to another group plan that does meet the criteria of the Act.

As an exception to the general principle that all groups covering Quebec residents are subject to pooling, the QDIPC allows a participant to exclude from pooling employer groups that do not have places of business in Quebec and that offer coverage not meeting the minimum criteria of the BPDIP. The application of this rule must be consistent over time. A participant wanting to take advantage of this exception must be able to provide, upon simple request by the QDIPC or its agents, proof of the grounds for the group being excluded from pooling.