Extended health care benefits – Benefits Fact Sheet 1

This contains general information and is intended as a reference only. It is not a substitute for independent legal advice regarding your situation. Printable PDF

Insurance companies, through the employer and under a group insurance plan, offer extended health care benefits beyond what is provided under Government plans (e.g. OHIP and Assistive Devices Program).

Benefit coverage can vary greatly from plan to plan. You should review your collective agreement and your benefit booklet to determine what your coverage is. Every plan will have a list of exclusions. If you are unsure, you should contact the insurance company directly before you purchase any item.

If you are a new employee, confirm when you can start to use the benefits before purchasing any item.

In order for coverage to be extended to provide for a benefit you believe should be included, it will likely need to be negotiated with the Employer in a future round of bargaining. The key to negotiating any change to your Collective Agreement is mobilizing your membership around issues that are important to you, early and often.

Eligibility for Coverage

The health plan will be effective from the date selected by the employer and stated in the contract with the benefit carrier. Individual employees who are eligible under the plan will have their coverage effective as early as the date that a completed application (enrollment form) is received by the employer, provided that it is not received later than one month following the effective date upon which the employee would have normally become eligible.

If the application is later than one month, eligibility may be restricted until “evidence of insurability” satisfactory to the carrier is submitted and approved (medical evidence of good health). The general practice is to cover employees currently employed by the employer on the effective date of the plan. If the employee is not “actively at work” (e.g. on sick leave) on the date that coverage would have become effective, coverage may not begin until “active full-time employment” resumes.

Payments

Reimbursement or Pay Direct Plans

A pay direct plan pays the provider of the service directly (e.g. drug cards, paramedical providers or vision providers). Under a reimbursement plan, the employees must pay the health care expense and then claim reimbursement from the insurer for that service.

Deductibles

Many plans contain a type of cost-sharing called deductibles. A deductible is the flat dollar amount of expenses an employee must pay out before the insurance company will start paying. For example, if there is a $100 deductible per family for drugs, the family will pay the first $100 of drug expenses every year and then the Insurer will start to reimburse drug expenses.

Co-Insurance

A co-insurance feature provides a formula under which an employer’s health care costs will be shared with the employee. It is usually expressed in percentage terms (e.g. 10%, 20%, 50%). It is often found in health and dental plans. It may be used in combination with deductibles.

Maximums

This provision places a ceiling (a maximum) on amounts that may be claimed for medical or dental expenses by the employee. Most supplementary health and dental plans have one or more combinations of the maximum.

A maximum can be levied in three ways:

• annual – annual amount for total claims (e.g. $2000 per year)
• lifetime – lifetime limit (e.g. orthodontics $1500 maximum)
• frequency – a limit on use of service (e.g. 2 dental visits per year, number of times a drug can be dispensed)
• Reasonable & Customary (R&C) Maximum is the highest amount an insurance company will cover for a specific medical service based on industry standards.

Sometimes, there is an effort to reduce costs by limiting the frequency. An example of this is the insurance company paying for a routine dental checkup not more than every 9 months, instead of every 6 months.

Reasonable and Customary Maximums

Reasonable and customary describes the amount a group benefits provider (i.e. insurer) would expect a health, dental or extended health care provider to charge one of their members for a service. The insurance company establishes those amounts – considered a ‘realistic and expected’ charge for a service – as a starting point for settling claims.

Based on what that reasonable and customary amount is, the insurance provider then determines

how much of what a member is claiming will be covered, according to that member’s plan.

Expense amounts are subject to reasonable and customary limitations because fees across different geographical locations vary. In addition, some health care providers charge more than others for the same service, due to individual fee schedules.

Insurance companies adjudicate claims based on what they determine as the standard amount charged for a particular service, according to:

• the prevailing rate for that service provincially
• fee guides for a specific profession under its regulatory body (e.g., dental fee guide, medical association guide)

Pre-determination

It is recommended that you request a pre-determination from the insurance carrier for any item over $200, or if you are unsure that the benefit you wish to purchase will be covered. A predetermination of benefits is a form or letter that is sent from your medical or treatment provider to your insurer before undergoing treatment. Your insurer can review the proposed treatment and determine how much will be reimbursed by your plan.

How to do a Pre-Determination

• Gather your information (name, birthdate, insurance ID etc.)
• Identify the procedure or treatment (include detailed treatment plan and necessary documentation)
• Complete the pre-determination request form
• Submit the request to the insurance (via fax, email or insurance online portal)

Why should you request a predetermination of benefits?

Whenever you’re about to undergo new or expensive medical treatment or dental procedures, it’s a good idea to find out up front how much your treatment will cost, how much your insurance plan will cover, and whether you’ll have any out-of-pocket expenses.

Submitting a Predetermination of Benefits

To determine coverage in advance, submit a predetermination or claim form detailing the proposed treatments, tests, or necessary medical equipment to your insurance provider. They will typically respond with a statement outlining the expected reimbursement amounts.

How You Can Benefit

Submitting a predetermination of benefits notifies your insurer of your upcoming claim, streamlining the adjudication process. This can lead to a shorter waiting period and faster payments. Additionally, it helps you avoid unexpected out-of-pocket expenses.

Co-ordination of Benefits

Coordination of benefits is an important provision under extended healthcare contracts that allows you and your spouse to coordinate benefit payments under your respective health and dental plans, if each partner has elected family coverage.

For example, a drug benefit may provide only 80% coverage on your plan and your partner’s plan has similar coverage. You submit your claim to your insurer, and you will be reimbursed 80% of the eligible amount. Once you have received payment on the first amount, your partner submits the difference to their plan. The second plan will pay the lower of:

• The amount payable had it been the first plan; or,
• Up to 100% of the eligible expense less the amount paid by the other plan.

For parents who are cohabitating and/or married, dependents’ claims must be submitted by the parent whose birthday is closest to January 1 and then once the insurer has paid, the balance is submitted to the other parent’s insurer to recover the difference.

For other parenting arrangements, it’s best to check with your specific insurance plan for instructions on submission.

Types of Benefits

Drugs

Drug plans vary, and it is important to understand what you are covered for. Some drug plans use a formulary and will only pay for certain drugs. They may insist on the substitute use of generic drugs where available. Other plans may pay for any drug, so long as it has a Drug Identification Number, while other plans may only pay for drugs that legally require a prescription.

Most plans these days offer a drug card. When you have a drug card, you need only pay for the portion of your prescription that is not covered under your drug plan. Each plan varies depending on what is negotiated and can cover up to 100% of the drug cost or a lesser partial percentage and/or a deductible amount (i.e. $3 or $5 for each prescription).

Some drug plans may be “tiered” meaning that you must try older and/or less costly drugs and show that they don’t work for your medical condition before the plan will cover the newer and/or more costly drug available for the same condition. The insurance company may require that you get special authorization before they will pay for very costly medications. When in doubt about your coverage, it’s important to contact the insurance company to clarify what they will cover and under what circumstances.

Government assistance may be available in managing high drugs costs. Check the resources section of this sheet for more information.

Paramedical Services

A few examples of paramedical coverage for health care treatment include Chiropractors, Registered Massage Therapists, Physiotherapists, Osteopaths, Naturopaths, Psychologists and Dietitians. This is just a short list, and there are many other types of treatment providers that may be covered under your extended health care benefits. Payment may be claimed as a maximum amount per visit, a maximum per hour and/or a yearly maximum. Be sure to check your benefit booklet.

To be reimbursed for paramedical expenses under your plan it’s important to ensure that:

• the service is covered under your plan;
• the provider is someone who is licensed in the province in which they are practicing;
• the provider is practicing within the scope of their license;
• the receipt has the name, title, address, date of service and their registration number if applicable
• a copy of the referral (if required under your plan), AND
• Your insurance company hasn’t “delisted” the provider (see below for further information).

A Massage Therapist who is registered in British Columbia may not be eligible for reimbursement in Ontario. They would need to be registered with the Ontario College of Registered Massage Therapists to be reimbursed by the insurance company for treatment provided in Ontario. Ensuring that your treatment providers are licensed protects you as a consumer and ensures that the insurance company will not reject your claim for treatment.

Insurance companies from time to time, may investigate a provider and “delist” them. This is because this provider has allegedly been found by the insurance company to have inappropriate business practices (e.g. submitting improper claims, potential benefits abuse and/or disciplinary action by the regulatory body). If this happens, your insurance company will not pay and/or reimburse you for any services rendered by this provider. Therefore, it is imperative that you check the “delisted” providers list from your insurance company often, particularly before you visit a new provider, or one that you haven’t visited recently.

Some benefit plans may require a referral from your doctor for a service to be covered.

Durable Medical Equipment

Durable medical equipment are items like wheelchairs, crutches, hospital beds and other equipment that you may require to be mobile, or that may assist you in your activities of daily living. Your plan may only pay for rentals of this type of equipment or require pre-authorizations prior to purchase.

Given this type of equipment can be expensive it is best to check with your insurance company on what they will cover, and under what conditions. Surprisingly, many items’ doctors prescribe are not covered under insurance plans. The Provincial Government under the Assisted Devices Program may offer partial or full payments for some items. An explanation on how to access this program is given below.

Vision and Hearing Care

Vision care covers costs associated with a visual impairment, and plans may provide for some or all the following: eyeglasses, contact lenses; routine and special eye exams, laser surgery, glasses and lenses following cataract surgery and other eye related treatments and/or services.

Generally, eyeglasses that are not required to correct a visual impairment will not be reimbursed by a plan. A prescription will always be required. Some plans may allow for tinting of lenses (sunglasses) while others may not. Check your benefit booklet or with the insurer.

It’s useful to know that many benefit plans have “liberated” the benefits so that money allocated for eyeglasses/lenses/frames may be used towards laser eye surgery even if the plan itself does not cover this procedure. Check with your insurance company to find out.

Hearing care provides for hearing aids and sometimes, other assistive devices for the hearing impaired. Hearing aids may also partially covered under the Province of Ontario Assistive Devices Program.

Hospital

Most hospital expenses are covered by the Ontario Health Insurance Plan (OHIP). However, OHIP does not pay for semi-private or private rooms for acute care if they are not medically necessary.

Many plans, however, do provide coverage for either semi-private or private rooms at a partial or full subsidy. You will be responsible for the difference between the partial amount and the actual cost if you elect to use this benefit. You do not have to use the benefits and the hospital will not charge you, but you need to tell them at the time of admission. If you use this benefit, you may get a letter from the insurance company asking you to verify that you utilized a semi-private or private room before they pay the hospital for the service.

Nursing Services

To be covered for nursing services, you must show that the requested services can only be performed by a licensed nurse. Insurance companies will not pay for nurses to be used as caregivers.

You are usually required to get pre-approval for these services before the insurance company will reimburse for them. It is best to get a medical note from a physician confirming the need for the service and to what level, when making the request. The insurer can approve and, in some cases, pay for the services directly to the nursing agency.

Orthotics and Orthopedic Shoes

Usually custom-made orthotics and/or orthopedic shoes will require a prescription from your doctor. In order to be eligible, they will need to address a foot problem (i.e. they need to be medically necessary). Off the shelf shoes and orthotics, or shoes specifically purchased to fit orthotics are not usually eligible for reimbursement. However, costs for some off the shelf orthopedic shoes may be reimbursed if they have been specifically modified for your foot.

Orthopedic shoes are an area of concern for both insured members and insurers these days because of wide-spread insurance fraud. To address this, insurance companies are now seeking a lot of information about the shoe and/or medical condition prior to approving payment. Many claims are being rejected.

It is also important that you review what is required to be reimbursed. If you require a prescription, ensure you are attending the correct specialist for that prescription, and that they have examined you and diagnosed the condition that the equipment will be correcting. In addition, before purchasing ensure that the cost of the shoes/orthotics is reasonable. Sometimes a provider may ask you what your insurance will cover and then charge you that amount. This can be greatly inflated, and you will only be reimbursed for the usual (reasonable) and customary charge.

Play it safe! Get a predetermination in writing prior to purchasing orthopedic shoes or orthotics. Contact your insurer to find out how to do this. Do not rely on your benefit plan booklet or the provider for the information on what your plan will cover.

Out of Province / Country Coverage

Some plans offer coverage for out-of-province/country travel. Carefully review your coverage before you travel, and if your plan has low maximums, co-payments, matches what OHIP pays or the like, buy additional travel insurance. Taking a trip without this insurance could be a very costly and possibly the worst decision you ever make.

Bargaining Benefit Improvements

Should the insurer correctly deny the coverage, but you believe this coverage is important for your employer to provide, it will be important to identify the lack of coverage to your local leadership and colleagues. In order for coverage to be extended to provide for the benefit you believe should be included, it will likely need to be negotiated with the Employer in a future round of bargaining.

If you and your colleagues believe a specific benefit is important, providing information, education and resources to your local leadership and your colleagues will be important to garner support for the change you want to see within your Collective Agreement. Bargaining begins essentially as soon as a Collective Agreement is ratified, meaning, you need to provide information and education to your co-workers often and early. That way, when your next round of bargaining is imminent, the seeds have already been planted and you’ll ideally already have the support necessary to support the change you want to see. If you’ve rallied your colleagues, they too will ideally complete the bargaining survey and attend the demand set asking for the change to the Collective Agreement.

Resources

Government Sponsored Programs to Help with Medical Costs

Generally, to be eligible for any of the services, you must live in Ontario and have a valid Ontario Health Card (OHIP). In some cases, further conditions apply.

Assistive Devices Program (ADP)

The Assistive Devices Program (ADP) helps cover the cost of specialized supplies and equipment. ADP covers over 8,000 separate pieces of equipment or supplies in the following categories:

• prostheses;
• wheelchairs/mobility aids and specialized seating systems;
• enteral feeding supplies;
• monitors and test strips for insulin-dependent diabetics (through an agreement with the Canadian Diabetes Association);
• hearing aids;
• insulin pumps, continuous glucose monitor and related supplies for those with Type 1 Diabetes who meet certain eligibility criteria;
• respiratory equipment;
• orthoses (braces, garments and pumps);
• visual and communication aids;
• oxygen and oxygen delivery equipment, such as concentrators, cylinders, liquid systems and related supplies, such as masks and tubing.

ADP pays up to 75 per cent of the cost of equipment, such as artificial limbs, orthopedic braces, wheelchairs and breathing aids. For others (for example, hearing devices) the ADP contributes 75% up to a maximum amount. In most cases, the client pays a share of the cost at time of purchase and the vendor bills ADP the balance. For device categories, such as ostomy supplies, breast prostheses, insulin syringes for seniors, and enteral feeding pump & supplies, the ADP pays a grant directly to the person to contribute towards the purchase of eligible devices and/or supplies from any retailer that sells these products.

For ADP clients receiving social assistance benefits through Ontario Works (OW), Ontario Disability Support Program (ODSP) or Assistance to Children with Severe Disabilities (ACSD), the ADP will pay 100% of the ADP-approved price or maximum amount.

In most cases, the client pays a share of the cost at time of purchase and the vendor bills ADP the balance.

For ADP supply categories where grants are paid, the client pays 100 per cent of the cost to the vendor.

There are many sources of funding for the client’s share of the cost including clients, voluntary/charitable organizations e.g. March of Dimes, The Easter Seals Society, Kiwanis, Lions Clubs, social assistance, Department of Veteran Affairs and insurance companies.

Eligibility includes any Ontario resident who has a valid OHIP card issued in their name and has a physical disability of six months or longer. Equipment cannot be required exclusively for sports, work or school. ADP does not pay for equipment available under the Workplace Safety and Insurance Board or to Group “A” veterans for their pensioned benefits. There are specific eligibility criteria which apply to each device category.

An individual who has a chronic illness or dysfunction that requires long-term oxygen therapy may be eligible for home oxygen funding.

For more information:

Ministry of Health and Long-Term Care Assistive Devices Program

• 7th Floor, 5700 Yonge Street Toronto, ON M2M 4K5
• 416-327-8804, Toll-free 1-800-268-6021, TDD/TTY 416-327-4282 or 1-800-387-5559
• Fax 416-327-8192
• e-mail: [email protected]
• website: https://www.ontario.ca/page/assistive-devices-program

Trillium Drug Program

Is available to people who live in Ontario who have high prescription drug costs compared to their household income. The Trillium program will cover the full cost of prescription medication until the end of the program year, once you hit the maximum spend threshold. To receive funding through the program, you will be required to pay a deductible equivalent to 4% of your net income (this is the maximum spend threshold). Once you have paid the deductible, your Trillium Drug program coverage begins and you will only pay up to $2 for each drug that is filled or refilled until the end of the program year. The deductible payment is split into 4 payments made quarterly. Once you have paid your deductible for the 3-month period, the Trillium program will pay the rest of your medication costs for that period.

You can apply to Trillium if:

• You live Ontario
• Have a valid Ontario health card number
• Do not already qualify for the Ontario Drug Benefit Program
• Do not have an insurance plan that pays for 100% of your drugs
• Spend about 4% or more of your after-tax household income on prescription-drug costs

OHIP+

Provides coverage for more than 5,000 drug products that are currently available through the Ontario Drug Benefit program to anyone 24 years and under who has OHIP coverage and is not covered by a private plan. Enrolment is not required as access is automatically granted. Coverage stops on the child’s 25th birthday or if your child becomes covered by a private plan.

Patient Assistance Programs

Many pharmaceutical companies offer patient assistance programs (PAPs). PAPs are available to patients who despite their insurance coverage, are unable to afford the out-of-pocket costs for medications. These programs will typically reduce or offset the out-of-pocket costs as those costs will be paid by the drug manufacturer.

What to do if you are denied a benefit by the Insurance Company?

Reasons for a denial will be outlined in the predetermination or explanation of benefits from the insurer and can include:

• Insufficient documentation was submitted
• There is no coverage under your plan for the type of benefit you are requesting
• You have already reached your maximum allowed – yearly or lifetime

You should call the insurer and inquire why you were denied and if there is any additional information you need to submit that would allow the claim. Keep copies of all paperwork you submit and receive from your insurer. You may need this documentation later on if there is a dispute.

If the insurer maintains the denial and no further documentation will assist, then contact your employer and/or local union representative to confirm your coverage, and if the claim was correctly denied.

OPSEU/SEFPO does not represent members in appeals for extended health care benefits unless there is a formal Joint Insurance Committee in place through your collective agreement. You may have the option to grieve denial of your extended health care benefits. You should refer to your collective agreement and/or contact your local representative.