Health insurance provides you with protection against financial losses from the expenses related to an illness or injury and is an extremely valuable product. Health insurance can cover many of the health and drug expenses not covered by Provincial health care.
Accidental Death and Dismemberment:
Commonly referred to as AD&D, this benefit provides a lump-sum payment in the event of death due to accident, and a lesser lump sum in the event of the loss or loss of use of the Insured’s body parts as a result of an accident. This benefit may be included with a health insurance plan or available as an add-on, at an additional cost.
Benefits are payable for these services after the yearly maximum allowed (if any) under the Provincial health plan has been reached.
Paramedical services typically include:
- Speech Therapist
- Ophthalmologist or optometrist
- Registered massage therapist
Health insurance will typically cover the purchase or rental of medical supplies such as:
- Cervical collars
- Ostomy supplies
- Non-motorized hospital beds
- Diabetic supplies
The insurer will usually set an annual maximum for all medical supplies covered under the health insurance plans, such as $2,500.00 per year.
Health insurance may also include:
- Prostheses and accessories
- Accidental dental coverage
- Hearing aids
Prescription drug coverage will typically cover prescribed drugs that are not available over the counter. The drug coverage will normally cover the lowest cost generic drug available. The private insurance sector is responsible for the majority of all drug expenditures, making this one of the most valuable forms of any insurance plan. Drug limits vary from $500.00 for a guaranteed issue (no medical) plan up to $10,000.00 for a medically underwritten plan. Adding catastrophic health insurance coverage as an add-on to a medically underwritten plan can provide a much higher amount of drug coverage and peace of mind.
Virtually all plans will provide the Insured with a drug card that is to be presented to the pharmacist when purchasing a prescription.
Vision care is often included with most health insurance plans and provides reimbursement towards the cost of prescription lenses, frames and contact lenses. The amount ranges from $100.00 every two years to $300.00 every two years. This benefit may also include coverage for eye exams.
Emergency Travel Medical Insurance:
Emergency travel medical insurance covers the insured for the cost of emergency hospital and medical care when travelling outside of their province of residence or out of the country. The benefit typically covers an unlimited number of trips per year up to a specified number of days per trip, for example 5, 9, 17, 30, 60, or 90 days. Some plans will offer the option of adding on extra days to the core plan at the time of applying for coverage. One can also purchase top-up coverage later if eligible.
The contract will outline what pre-exiting condition limitations are applicable and what constitutes a pre-existing condition. Generally, a pre-existing condition includes any condition for which the insured had any symptoms, visited a doctor or was advised to do so, sought medical treatment, or took/was prescribed medication, whether the condition is diagnosed or not, if the item in question occurred within a specified period of time prior to departure. Generally, the time frame prior to departure varies from 90 days to 180 days but could be longer.
The pre-existing condition period is measured from each departure date from the home province and is not measured only from the plan’s inception.
Catastrophic Health Insurance Coverage:
Some insurers offer the option to apply for enhanced coverage to protect against catastrophic loss from serious accident or major illness at a reasonable rate. A deductible must first be satisfied, typically from $4,500.00 to $10,000.00 or more, after which the insured is protected against large drug and medical expenses. There may be limits per incident. Some plans have maximums, and some provide unlimited coverage, with or without a lifetime maximum.
When designing the core plan, one should consider the core plan’s drug limit and the deductible for the catastrophic coverage to allow for seamless coverage.
Hospital coverage may be included in a personal health insurance plan or available as an optional add-on. This feature provides for the additional cost of preferred over basic accommodation to be covered up to a stated maximum charge per day and a limited number of days per year.
Medically Underwritten v. Guaranteed Issue Health Insurance Plans:
A medically underwritten plan offers higher annual maximums because the insurer has the opportunity to review the applicant’s health in advance and determine the basis on which coverage will be offered. An underwriter will look for existing conditions, medication used or prescribed and not taken among other factors and typically approve, decline the coverage and for some plans, apply exclusions. The underwriter may request information from the applicant’s physician and review medical records. Though not common on every case, a paramedical, urine specimens or a blood chemistry profile may be asked for.
Some insurers will offer coverage but exclude all existing medications. Others may exclude the underlying condition(s) or decline coverage.
A guaranteed issue plan does not require applicants to complete a health questionnaire but will typically offer coverage on a limited basis when compared to coverage that is available on a medically underwritten plan. That being said, Guaranteed issue plans are ideal for those with pre-existing conditions that cannot get approved though traditional means.
The deductible is the amount of eligible expenses that the insured pays each year before coverage begins. The deductible is paid before coinsurance is factored into the payment calculation of a claim.
In addition to the deductible, the plan will usually have a coinsurance factor. Coinsurance is the cost-sharing percentage between the insured and the insurer. The term coinsurance typically refers to the percentage that the insurer will pay, and the co-payment represents the remaining percentage that must be paid by the Insured.
For example, if a plan has a $25.00 deductible and an 80% coinsurance, the insured will pay the first $25.00 of eligible medical expenses each year, after which the insurer will pay 80% of the remaining eligible expenses incurred up to the stated maximum. The other 20% of the eligible expenses is known as the co-payment and is paid by the insured. In summary, the Insured pays a 20% co-payment on each $1.00 of eligible expenses incurred in addition to the $25 deductible.
The deductible and coinsurance factors will vary from plan to plan.
A maximum time period may be used, such as a calendar year, benefit year or anniversary year. A calendar year follows the twelve-month calendar year, from January to the end of December. A benefit year means the period of 12 consecutive months following the date a claim for a specific benefit is first incurred. An anniversary year is the consecutive 12-month period following the effective date of the insurance coverage and annually thereafter. Plans may use any one or all of these definitions.
In addition to annual maximums by benefit category, EHC may be subject to a lifetime maximum, such $100,000.00, or $250,000.00.
Some plans will limit or cap the amount that will be covered for the pharmacist’s dispensing fee. Any amount charged over the set cap must be paid for by the insured at the time that the medication is purchased. A dispensing fee is the fee charged for the professional services of the pharmacist when dispensing a drug which includes explaining how to take the drug and any side effects. Ontario pharmacies must post the fees in view of consumers when they fill a prescription. Dispensing fees vary from pharmacy to pharmacy ranging from $6.00+ to $14.00+ while most pharmacies are typically charging in the $10.00-$12.00 range. Some plans may share the dispensing fee (50%) with the insured. Shopping around for a lower dispensing fee could save you money.
Dental insurance services are categorized by type of care such as basic, preventative or routine care, major restorative and orthodontic services. Typically, personal dental insurance plans base benefit amounts payable on the reasonable and customary charges up to the fee guide in effect where the covered individual resides. Many personal dental plans that are purchased as stand-alone plans (dental only) will typically include some minimal level of extended health care as well.
- Diagnostic procedures including dental exams, a limited oral exam (recall exam), x-rays and laboratory reports.
- Preventative procedures such as teeth cleaning, polishing, light scaling, topical fluoride/sealants and other preventative procedures.
- Dental surgery (other than accidental) such as removal of impacted teeth, diagnostic x-ray and laboratory reports in relation to the dental surgery.
- Minor treatment to restore the functional use of natural teeth through the use of amalgam, silicate, acrylic and composites, pit and fissure sealants. Repair may be for damage due to wear and decay.
- Periodontal services to treat the bone and gum around the tooth, including deep scaling, mouth guards and periodontal appliances.
- Endodontic services to treat the root of the natural tooth such as a root canal.
- Major restorative to restore the normal function of the natural tooth with artificial appliances such as crowns, inlays and onlays.
- Prosthodontic services which are designed to replace missing teeth and structures with removable appliances such as full or partial dentures and non-removable or fixed appliances such as bridgework, crowns/caps and veneers.
- Orthodontic procedure required for the prevention, diagnostics and correction of dental and oral irregularities, as well as defects of the jaws through the use of corrective devices such as wires, tooth bonding, braces, space maintainers or other mechanical aids used to reposition teeth. Typically, orthodontic services are limited to dependent children under a specified age, usually under 19.
Personal dental insurance payment calculations are generally based on deductibles, coinsurance and maximums.
The deductible is the amount of eligible expenses that the Insured pays each year before coverage begins. The deductible is paid before coinsurance is factored into the payment calculation of a claim. Most personal dental plans do not have deductibles.
Coinsurance is the percentage of eligible expenses (after the deductible is applied) eligible for reimbursement under the dental insurance plan. Coinsurance levels vary based on the type of service from 50% (typical for major and orthodontic) to 100%.
Personal dental insurance plans typically have some type of tiered maximum built-in which is based on the coinsurance, maximum or type of service. For example, a basic plan might cover 50% of the first $1,000.00 of basic services in year one, in year two and beyond it might cover 80% of the first $400 and 50% of the next $900. Most personal dental insurance plans will cover endodontic and periodontal services starting in the second year of coverage and if they include major dental or orthodontics the coverage will typically start in year three. When personal dental insurance is purchased as a package with full healthcare the maximums may be more comprehensive.
Frequency and Recall:
Dental recall limits how often certain dental benefits are paid such as routine check-ups, cleaning, scaling and x-rays. Basic personal dental coverage will typically have a recall of nine months for check-ups, where a more comprehensive plan may have a six month recall.
Predetermination of Benefits:
It is generally recommended (or required) that procedures expected to cost more than a pre-determined amount be reviewed by the insurer prior to treatment. This can be done by your dental office on your behalf.
We are proud to offer online quotes through our partner, Manulife Financial. Through CT Insurance Brokers Inc., you will always have access to independent insurance brokers, experienced service, and unbiased advice.
This plan is ideal for those with a limited budget, requiring minimal Practitioner coverage, requiring dental or drug only coverage, looking to top up an existing group plan. Manulife Flexcare also has flexible options, with add-ons and some stand-alone options, such as vision coverage, travel, accidental death and dismemberment, catastrophic drugs, hospital, or prescription drugs.
Manulife Association Plan:
This plan is ideal for those who have a higher budget, require higher practitioner coverage, brand-name prescription drugs (Gold plan), a plan that includes basic and minor dental coverage, are looking for more travel coverage and want easy to understand pre-packaged plans. Additionally, this plan is great for part-time employees who cannot obtain group benefits due to the limited hours that they may be working at one or more places of employment.
Leaving a Group Benefits Plan (Converting Coverage):
If you are losing your benefits for any reason, such as leaving employment or retirement, Manulife offers a great solution called Follow Me. You can apply for this plan within 60 days of the termination of your group plan and there is no medical underwriting required. You can obtain coverage even if you have a pre-existing condition. Follow Me also offers the option to add travel coverage (up to 69. coverage valid until age 80).
Speak with An Insurance Broker:
Online quote options are provided for you convenience; however, we highly recommend speaking to licensed insurance advisor. If you need help with the online quote options, an analysis of your needs or to speak with a licensed insurance advisor, please contact us today.