Terms and Conditions of Pooling
Pooling is based on terms and conditions that vary according to the covered group, i.e. on the number of certificates in the group (one certificate corresponds to one member, with or without dependents).
These terms and conditions incorporate two parameters, namely:
To be eligible, the claims must have been submitted and paid during the year in question and be for medications covered by the private plan;
- the annual pooling factor: for insured groups, this is a portion of the insurance premium reserved for compensation of the pooled amounts; for non-insured groups, it is an assessment paid to the Compensation Table for the purpose of pooling.
How do we define terms & conditions ?
A larger group is better able to absorb high claims from the sum of premiums or contributions paid. Therefore, the more certificates the group has, the higher the pooling threshold and the lower the annual factor.
The methods of mutualisation are established and validated on the basis of a test of reasonableness (Monte Carlo test) based on multiple actuarial assumptions. These assumptions take into account past claims, cost, and use of drugs.
Terms & conditions for 2023
The Quebec Drug Insurance Pooling Corporation (Corporation) establishes the terms and conditions of pooling for 2023.
| Size of group (no. of certificates) | Threshold per certificate 2023 | Annual factor Without dependants | Annual factor With dependants |
| Fewer than 25 | $10 000 | $276,00 | $771,00 |
| From 25 and 49 | $18 000 | $188,00 | $527,00 |
| From 50 and 124 | $32 500 | $100,00 | $339,00 |
| From 125 and 249 | $55 000 | $66,00 | $224,00 |
| From 250 to 499 | $80 000 | $50,00 | $169,00 |
| From 500 to 999 | $105 000 | $36,00 | $142,00 |
| From 1 000 to 3 999 | $130 000 | $31,00 | $123,00 |
| From 4 000 to 5 999 | $300 000 | $15,00 | $60,00 |
| 6 000 and over | Free market | Free market | Free market |
Adopted by the Board of the Quebec Drug Insurance Pooling Corporation on October 12, 2022
All plans are subject to the following conditions:
- The compensation formula uses paid claims per certificate exceeding the threshold, net of all discounts.
- The Pooling Terms and Conditions reflect target loss ratios of 93% for segments below $50,000 and 90% for higher segments
- Eligible drugs are those covered by the private plan including claims paid as a second payor.
Terms & conditions for 2022
The Quebec Drug Insurance Pooling Corporation (Corporation) establishes the terms and conditions of pooling for 2022.
| Size of group (no. of certificates) | Threshold per certificate 2022 | Annual factor Without dependants | Annual factor With dependants |
| Fewer than 25 | $8 000 | $276,00 | $771,00 |
| Between 25 and 49 | $16 500 | $188,00 | $527,00 |
| Between 50 and 124 | $32 500 | $97,00 | $328,00 |
| Between 125 and 249 | $55 000 | $66,00 | $223,00 |
| From 250 to 499 | $80 000 | $51,00 | $173,00 |
| From 500 to 999 | $105 000 | $39,00 | $153,00 |
| From 1 000 to 3 999 | $130 000 | $34,00 | $133,00 |
| From 4 000 to 5 999 | $300 000 | $18,00 | $71,00 |
| 6 000 and over | Free market | Free market | Free market |
Adopted by the Board of the Quebec Drug Insurance Pooling Corporation on October 13th, 2021
All plans are subject to the following conditions:
- The compensation formula uses paid claims per certificate exceeding the threshold, including claims paid as second payors.
- The terms and conditions of pooling reflect a target loss ratio of 93% for segments below $50,000 and 90% for higher segments.
- Eligible drugs are those covered by the private plan.
