Canadian Medicare promises universal healthcare for all Canadians and permanent residents, granting free hospital and physician visits in their respective provinces. According to the Commonwealth Fund, the federal government doles out financial resources so each province can implement its health insurance plan.
Questions arise about covered services and how people can get extended health coverage. The most common way to get extended health coverage is by securing employment with a healthcare benefits package through an insurance company. However, it’s essential to read the fine print when using these plans, and there may be times when you have to coordinate secondary coverage with a partner or spouse or purchase additional coverage.
Extended Healthcare Coverage: A Brief Overview
Some of the most critical healthcare services are not free in Canada. For example, dental care (for adults) and prescription drugs are not free. Other services not covered by public health insurance include massage therapy, physiotherapy, optometry, chiropody, podiatry and psychotherapy. These are called regulated services and are generally the same in every province.
Provinces sometimes offer low-cost options or alternatives under provincial insurance coverage, but you must put yourself on a long waitlist before seeing a specialist. For example, the Canadian Mental Health Association (CMHA) notes wait times of up to two and a half years for therapy services covered by the Ontario Health Insurance Plan (OHIP). Some people need services that go beyond provincial coverage. And even though they seem like luxuries, physicians often refer their patients for outside care. That’s where extended healthcare coverage comes into play. To avoid spending hundreds or even thousands of dollars and skip wait times, citizens and permanent residents must secure a benefits package with an insurance company.
Heather Carr, a part-time receptionist at Evolve Chiropractic and Physiotherapy in Toronto, mentions that some companies are more popular than others. “The most common companies we deal with are Manulife, Canada Life, Sunlife and GreenShield,” she says.
These companies offer coverage that employers provide their staff as part of a benefits package for the primary member who can also add children and their spouses to the plan; coverage that students can use while attending a post-secondary institution; and individual coverage you can pay for monthly.
The Fine Print and Important Details
No matter how you secure extended coverage, it is essential to understand several rules surrounding these plans. It is a complex case of showing up to an appointment, flashing your card and leaving a clinic without paying.
First, plans will only cover a certain percentage of every appointment. According to the Telus Health Provider eClaims Portal, which clinics nationwide use to submit insurance claims for patients, plans will only cover what they consider the “reasonable and customary charge” per visit.
In other words, if a clinic charges $100 for an appointment, your plan may consider just $75 a reasonable price, meaning you still owe the clinic $25. The same rules apply to picking up prescription drugs at the pharmacy; you might have a remaining balance to pay out of pocket.
Furthermore, most plans will only grant a certain amount of coverage for every service per year, and they will divide it how they see fit. This means that if your plan allows you $500 a year for massage therapy, they will not only stop covering appointments when you reach this limit, but they will also try to make it last a long time. For instance, if your massage costs $150 for 60 minutes, your plan may consider your limit of $500 and how you can make this amount last. So, they won’t simply cover $150; they may instead cover $110 and have you pay the $40 balance to make your coverage last longer.
Another critical reason to read the fine print is that some plans won’t cover your needed services. Or they require additional documentation for coverage.
Carr notes that at Evolve, which also offers massage therapy, clients are often disappointed due to not reading the fine print. “Sometimes patients think they’re covered for massage therapy but aren’t without a prescription from their physician, which they don’t have,” she says.
Lastly, it’s crucial always to plan to pay out of pocket on the day of your appointment, even with a benefits plan, because many clinics still collect money. In other words, clinics can offer “direct billing” or general “claim submission.” The former means that the insurance company will pay the clinic for your service, leaving you to pay the remainder or nothing. However, with the latter, the clinic will submit a claim on your behalf, and your insurance will reimburse you within a few business days, but it means you have to pay the clinic up front and wait to get your money back.
Is Securing Another Plan the Answer?
Extended coverage plans have strict rules. So how can you accommodate this to ensure you are either fully reimbursed for regulated healthcare services or don’t have to pay? Is buying an additional plan the right thing to do?
First, if you have a spouse with their insurance, you can usually use secondary coverage or benefits coordination. This is when you or the clinic submit a claim to your partner’s plan to reimburse what’s left after your primary insurance assesses the claim. It’s essential to check if clinics can do this, as you may have to do it manually.
If you don’t have a spouse with insurance, you can weigh the pros and cons of paying for an additional plan. If you like to use your benefits to ensure you stay in good shape but don’t need any particular service, you may not need to invest in this. Paying a small balance from time to time can be easy to manage.
However, paying those small remainders will eventually add up if you need regular appointments with a specialist, such as a physiotherapist after an injury or a dentist after an infection. This is when you can weigh the cost of purchasing an additional plan versus paying the balance.