Buying benefits for arthritis

Buying benefits for arthritis

Although there are many options to buying benefits, not all of these options will work or make sense for people living with pre-existing conditions, like arthritis. 

a female and a male looking at a formFor people who are self-employed or work on contract, health benefits and insurance are often not covered. This can be a big concern, particularly for people with arthritis or other chronic health conditions. Some treatments can be expensive and might not be covered by a federal, provincial or territorial public health plan. 

Because many private health insurance companies require you to pass a medical questionnaire to be approved for coverage or to receive a more comprehensive plan, finding a solution can be challenging. 

If you are considering buying your own benefits through a private health insurance provider, this resource explains some of the factors to take into consideration so that you can make an informed choice based on your needs.

Even if you do have prescription drug coverage, an extended health benefits plan that covers dental care, vision care, and complementary therapy may be more economical than paying for each of these services out of pocket each year. It will depend on your personal circumstances. 

Private health plans are frequently changed and updated by insurance companies, so it is always best to call insurance companies for more information about how to meet your specific needs. You can also speak to your local pharmacy about drug coverage options under public health plans or pharmaceutical company programs. 

Buying your own benefits

Buying your own extended health benefits may be helpful for some people with arthritis who are self-employed or working in the gig economy, it will depend on your needs and the plans available. There may be some hurdles to finding a benefits package that covers all the medications or treatments you may need. 

Medical questionnaires

Most companies selling private health insurance in Canada require applicants to pass a health questionnaire to assess the financial risk of accepting you as a client. Often medications that you are already taking will be excluded from coverage and considered to be pre-existing unless you apply for a continuation of an existing plan or for a guaranteed acceptance plan.  

Guaranteed acceptance plans

Guaranteed acceptance plans are a good way to still buy extended health benefits without having to pass a medical questionnaire. 

A guaranteed acceptance plan may be one of the only options available to you if you are not leaving a group benefits plan or have had difficulty passing medical questionnaires for insurance purposes in the past. 

This type of plan does not require a medical questionnaire; however, it may not provide as much coverage for medications and is usually more expensive compared to other extended health plans that require a medical questionnaire.

Continuation plans

Another way to buy benefits without having to pass a medical questionnaire is to apply for a continuation plan. 

Someone filling a paper formContinuation benefit plans, sometimes also known as roll over benefits, are designed for people who are leaving coverage from attending post-secondary school, a job with group benefits, or the coverage of a family member. They provide a short window of time – often 30-60 days – to apply after leaving your previous coverage. 

This can be a great option to receive more complete coverage without having to pass a medical questionnaire. If you know you will be leaving a group benefits plan, it is best to speak with an insurance company about what options offer you the best coverage for your needs before you leave your current coverage. 

Selecting an extended health plan

Many health insurance companies offer comparison tools on their websites to help you understand what each plan covers and provide a cost estimate for the monthly premium. This is a good way to get an initial understanding of what type of plan might be best for your needs. 

If you are not sure about any of the details or fine print, call to speak with a representative who can answer any questions you may have. 

Keep in mind that different companies offer different types of coverage, and some offer more than others for the same or less cost. Consider getting more than one quote for coverage to ensure you know what options best fit your price range.

What to look for

Not everyone will need the same things in a prescription drug plan or extended health benefits plan. Depending on the type of arthritis you have and your symptoms, more than a basic plan may be needed. Below are some things to consider when choosing a plan for arthritis care:

  • Is there a dollar limit (price cap) to the cost of prescriptions covered each calendar year?

  • If you take biologics or biosimilars, are these included under prescription coverage?

  • Is vision care coverage included?

  • If you use orthotics, are these covered by the plan?

  • How frequently are dental check-ups included? 

  • How much coverage is there for dental work, such as fillings or other dental procedures?

  • How much coverage is there for complementary therapy treatments such as acupuncture, physiotherapy, massage? Are they separate yearly amounts, or combined totals?

  • Does the plan offer disability or critical illness coverage?

  • If needed, what is the cost to also cover children or a spouse under your plan?

Prescription drug coverage with a provincial or territorial plan

While drug coverage is also available through provincial and territorial plans, coverage with these plans vary depending on where you live. In Quebec for example, everyone must have prescription drug coverage, either through the provincial system, or a private insurance plan. 

Older female with glasses looking at some documentsProvincial and territorial plans are often geared to income, meaning that each individual or family has a fixed payment, or deductible, based on their household income that you would need to pay to use this type of benefits plan. Sometimes this cost is distributed through smaller payments made as a percentage of the total cost of your prescriptions, known as a co-pay. 

For example, if you must pay $200 a year, you will pay a small fee each time you fill a prescription until you have paid $200. Other plans may have you pay the first $200 of your prescriptions, and then cover remaining prescriptions costs for the year. Each plan is different, and the amounts used here are as an example only. 

Although meant to fill a gap in prescription drug costs, these plans do not cover extended health benefits such as dental care, physiotherapy, or vision care. However, in some regions, the government may cover some or all of these services for particular groups, such as seniors, children, low-income individuals, or Indigenous individuals. Check with your provincial/territorial ministry or department of health for more information.

For those receiving unemployment or disability benefits or select federal health plans, prescription medication, vision and dental coverage are available, though it may require additional advocacy to receive coverage for some arthritis treatments. 

Vision care is covered by most provincial or territorial health insurance for regular checkups if you have an eye condition, such as uveitis, regardless of age. Often working age adults are not covered for regular vision check-ups unless outlined in their coverage, either public, or private.

Cost considerations

Buying personal extended health benefits can be costly. However, they might be worth considering if your personal out-of-pocket health expenses each year will exceed the cost of paying premiums for the extended health coverage. 

Consider how much you spend on prescription medication each year in addition to all other costs from eye exams, dental care, orthotics, mobility aids and complementary therapies. 

Don’t forget 

  • to include the additional co-pay fee you would need to pay as part of your plan when comparing your current costs to potential costs with an extended health plan. Ex. If your drug plan pays 80% of the medication cost, and the total medication is $100, you would pay $20 to fill this prescription. If you need to refill this 4 times a year, be sure to add the additional $80 when making your cost comparisons for different benefit packages. 

  • to claim the cost of the health care plan premiums on your income taxes 

Mix and Match

Many companies offer mix-and-match plans. If you do not need prescription drug coverage for instance but would like to explore coverage for complementary therapies or dental care, many insurance companies offer these separately. 

Combining plans

Younger female in conversation with a male holding some paperworkIf you are covered by a family member’s plan but routinely go over your limit for the year, or if you have high out of pocket expenses for medications or other therapies, consider combining an additional benefits plan with your existing coverage. Circumstances will vary, so it is best to check with your health insurance provider about how this might work for you. 

If you are self-employed, working freelance, contract, or gig economy jobs, it can be difficult to get the financial support you need to maintain your health and wellbeing. Considering all your options to reduce your overall health costs, which might include buying your own benefits, may help to reduce the stress of not having coverage through work. 

For some people, it might not make financial sense to invest in a private benefits plan if the premiums are too high or the coverage too minimal. For other people, buying benefits may help offset the costs of their medical expenses. Whether buying a benefits plan is the right decision for you will depend on your circumstances and the plans available.