New health plan for federal workers has some members feeling like they 'fell through the cracks'

Louise Sullivan stretches a brace across her husband's knee, then holds his arm while he attempts to hobble from their living room to the kitchen and back.

Michael Fairhead is noticeably exhausted. As is she.

The Ottawa couple — both retired federal public servants in their mid-sixties — used to live an active life, travelling the world before Fairhead lost function in most of his right side after a stroke eight years ago.

But Sullivan believes what little mobility he still has would not have been possible without years of intensive physiotherapy, something she says will now be reduced significantly after the government of Canada made a series of changes to the country's largest health insurance plan — the Public Service Health Care Plan (PSHCP).

"Without the physio, what's going to happen is his body is going to atrophy," she said.

"What I'm really worried about is he's going to get to the point where he won't be able to do anything on his own and I will be left doing all the things that he can now do."

Sullivan and Fairhead are among the 1.7 million federal workers, retirees and dependents who saw their insurance provider switch from Sun Life to Canada Life on July 1, and with it changes to what services and drugs are covered, how they're approved and what happens when they need to talk to an agent. 

The Treasury Board Secretariat (TBS), which oversees labour relations between the federal government and the public sector, said changes made to the PSHCP, including claim limits, coverage terms and eligibility, were approved in the fall of 2022 — independent of the switch to Canada Life. 

Those changes came into effect after Canada Life won a tender to administer the plan.

Still, CBC News has heard from dozens of members who say they're frustrated by both the government and the insurance provider. 

In Fairhead's case, coverage for his physiotherapy used to be practically unlimited.

Under the previous terms, the couple was covered at 80 per cent for claims up to $500 and claims over $1,000.

Now, it's capped at $1,500 annually. 

The cost for his physiotherapy last year was more than $14,000, according to Sullivan.

In response to the new cap, Sullivan said she's made the difficult decision to cut his physiotherapy from three days a week to once a week at most.

While she plans to help him with whatever exercise she can, she knows she won't be able to make up for the difference. 

"That's my biggest fear is that he's going to get to the point where he's going to be so sore and so stiff that he won't even want to get out of bed and that will devastate me," she said.

Drug coverage confusion

Along with coverage limits, the new plan dictates people must choose generic drugs.

Beverley Cormier, 59, recently switched to a new medication to help with flare-ups for her rheumatoid arthritis. Under her husband's plan, the first month was covered at 80 per cent by Sun Life, but when the next 30 days were set to go through, she learned from the drug's maker, Pfizer, that it had been declined by Canada Life.

"It's really hard how you can explain to people how one day you feel really good and then the next day you can hardly move and this medication was making such a big difference in such a short amount of time," she said, her voice cracking.

That medication comes with a $1,700 a month price tag.

I've maxed out my credit cards paying for the little medication that I do have right now.- Susan Judges, plan member

Cormier had only been on the medication for a month before the terms of the plan changed.

Her husband, Norm Cormier — a veteran who worked for the military for 27 years — contemplated coming out of retirement to find another job.

Not being able to get through to an agent at Canada Life after being denied twice for the medication compounded the frustration.

Canada Life has since covered the drug after CBC asked Treasury Board President Mona Fortier's office about it. The TBS told CBC the medication requires prior approval.

"When it's your medication and you're suffering, you just want somebody to tell you something," Beverley Cormier said.

She did suffer.

Because of the delay getting the medication approved, she went 10 days without it, resulting in a debilitating flare-up.

Susan Judges, 52, is also eligible for the plan because her husband is a veteran. She had to pay hundreds of dollars out of pocket for medications before problems with her plan were resolved earlier this month.

Despite calling four to five times a day since the switchover and sending emails, it took weeks before anyone from the company responded.

"I feel like we fell through the cracks," she told CBC.

Yet, she still faces weeks before being reimbursed the $300 because of ongoing problems with their enrolment — a decision between paying for food or medication.

"I've maxed out my credit cards paying for the little medication that I do have right now," said Judges.

The multitude of worries and frustrations are ones Roy Goodall has heard over the last few weeks.

"It's a terrible situation," said the president of the National Association of Federal Retirees. "I don't envy the people who are faced with this."

He said the association plans to address the cap on physio coverage with the government when there's a review of coverage in two years.

In the meantime, he's also heard from people who are frustrated with not being able to get through to an agent and being forced to do much of the enrolment or claims online when they're not technologically savvy.

"I understand that a lot of people are stressed, they're angry and they're frustrated that they're unable to reach anybody."

There are faces behind all of these numbers and decisions that they make and that real people are having their life affected to a very deep degree and I personally think it's appalling.- Louise Sullivan, retired federal public servant

Canada Life said it appreciates people's patience while it tries to deal with longer wait times to get through to an agent.

It blamed the higher call volume on those needing help enrolling in the plan, but said it's working with the government to help members have quicker access to their benefits and increasing call centre capacity to reduce wait times.

The company also urged members to contact pharmacies with their new Canada Life benefit card information to cut down on the number of claims being rejected.

TBS says changes mean greater access for more members

TBS said it continues to press Canada Life to come up with solutions to meet current call demands.

It pointed out prescription drug coverage is still reimbursed at 80 per cent, but a new $8 cap on pharmacy dispensing fees and a requirement for people to choose generic drugs means expanded benefits in other areas, including mental health, mobility devices and laser eye surgery.

It applied the same logic to the physiotherapy portion of the plan — by introducing a $1,500 annual cap, TBS was able to remove a barrier that had previously made some lower cost claims ineligible.

TBS said it had also tried to reach plan members in various ways ahead of the transition, including through the Annual Pensioners Statement and social media.

Sullivan understands how the change would likely provide access for more people, but she feels seniors with chronic conditions are being abandoned.

"For the majority of people, this is not an issue, But we are an aging population. Older people's limbs break a lot; 10 sessions is not going to help you recover," she said.

"There are faces behind all of these numbers and decisions that they make and that real people are having their life affected to a very deep degree and I personally think it's appalling."

CBC reached out to both the Conservative and NDP health critics. 

NDP Hamilton-Centre MP Matthew Green, who is deputy labour critic, called the move "alarming" and "unconscionable."

Green said he's concerned for families who are on fixed incomes.

"This feels a lot like a bait and switch by this federal government," he said.