Public and private health insurance in Quebec: how does it work?
If you live in Quebec, you are required by law to have insurance, whether public or private, that covers prescription drugs. Here’s how it works.
In Quebec, you are required by law to have insurance that covers prescription drugs. This insurance, public or private, reimburses part or all of the cost of the drugs you buy.
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Employers, unions, associations, and professional orders can give their employees and members access to a private plan. This insurance is part of the benefits they offer.
What is private health insurance?
Private health insurance is insurance that a person or an employer purchases from a private insurer. It is therefore not provided by the provincial or federal government.
A private plan provides coverage to a group of employees (or members). It is also called a “group insurance plan” or “group benefits plan”.
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What is public health insurance?
The Régie de l’assurance maladie du Québec (RAMQ) administers public health insurance in Quebec.
The RAMQ offers coverage to Quebecers who do not have access to private insurance, that is to say:
- persons not eligible for a private plan (for example, self-employed workers);
- people aged 65 or over;
- financial assistance recipients or claim slip holders;
- the children of persons insured by the public plan.
What are the requirements for a private health insurance plan in Quebec?
Quebecers covered by a private plan must include their spouse and children in their coverage – unless they are already covered by another private plan.
Those who have access to several private plans can choose the one they consider the most advantageous. This may be the plan provided by their employer or professional association, or that of their spouse.
In Quebec, private drug insurance plans must meet minimum requirements (which may be exceeded). They concern:
- the medications covered (for example, the RAMQ medication list );
- the financial contribution required from the participants. For example, it is a question of the plan’s reimbursement percentage and the maximum contribution for drugs on the RAMQ list.
What happens to your insurance when you withdraw?
If upon retirement, you are still eligible for a private plan, you are required to participate in it. This obligation ends when you turn 65.
If you do not have access to a private plan, then you must register with the RAMQ.
What happens to your insurance after age 65?
At age 65, Quebecers are automatically registered with the RAMQ public prescription drug insurance plan.
If you continue to be eligible for a private plane, you have a choice to make. You can choose to be covered:
- only by the public plan (if the private plan is a condition of employment, you must choose between options 2 and 3);
- by the public plan (first payer) and a private plan offering supplementary coverage (second payer); Where
- only through a private plan offering at least basic coverage.
The RAMQ will send you notice six months before your 65th birthday.
What happens if you switch from one plan to another?
Thinking of switching from a private plan to the public RAMQ plan? The list of covered drugs may be more restrictive. In addition, you will no doubt notice differences in the collection of deductibles and the percentage of reimbursement.
The reverse is also true if you go from public to private.
You might also see differences in coverage or the list of drugs covered. Except for the minimums required in Quebec, the provisions of private drug insurance plans can vary considerably. As of July 2020, the minimum coverage is 63%. The maximum annual contribution is $1,144 for drugs on the RAMQ list.
What happens if you use drugs that are subject to an exception or a special authorization? These are drugs for which your doctor has had to take special steps to ensure coverage. In this case, you may have to redo these steps to be covered by a new plan.
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Does the RAMQ check if you have health insurance?
In Quebec, you must be covered by insurance for your prescription drugs. The RAMQ regularly checks whether people who do not have a private plan are registered with the public plan.
If your situation changes, you must notify the RAMQ. For example, suppose you lose your job and therefore your benefits (including your group insurance). You must then inform the RAMQ that:
- your situation has changed;
- you are no longer covered by private insurance.
Same thing if you were covered by the public plan, but then obtained private insurance at work. You may even have to reimburse RAMQ for the amount they paid for your medication. Or you will have to pay the premium retroactively (either monthly or annual fees). If your employer does not offer such guarantees, you can turn to private insurance.