Understanding Your Coverage Options

Canada’s governmental health care is commonly known as Medicare. Medicare is legislated federally through the Canada Health Act, which identifies what health care services must be funded by the provinces and territories. Your doctor, hospital services and most diagnostic testing fall into this category.

Some provinces or territories fund other health care-related expenses such as medication, physiotherapy, glasses, dental and home care, but usually only for particular groups of people. These groups may include seniors, children and youth, people with low income, or those who are receiving social assistance. Some programs are also available to people with certain disabilities or illnesses. Some regions also pay for in-home or home care services.

If you’re not a member of a covered group, you will have to pay for these services another way, either “from your own pocket” or through a private insurance plan. Even in cases where your insurance covers your medications or treatments, you will often have to pay a portion of the bill yourself.

If you are admitted to hospital, the government will pay for the doctor services, medications and diagnostic tests ordered by the hospital. They also cover the services of “allied healthcare professionals” — health professionals who are not doctors — when they are requested while in hospital.

When you are discharged from the hospital, your coverage may change. Drugs and services that you received free of charge in hospital may become your responsibility. There are considerable differences from province to province in what is covered. The eligibility for public plans is set by whichever government is administering it. Usually only Canadian citizens and permanent residents are eligible.

Check with your provincial or territorial ministry or department of health for details about your public health insurance plan, what services are covered, and if you are eligible to receive coverage for additional healthcare services.

Private insurance plans are group plans usually sponsored by an employer, union or association. These plans pay some of the healthcare services not covered by your public plan.

If you are part of a group benefit plan, you will likely receive an information booklet or access to a website about the healthcare services that are covered. These may include:

• prescription medication,
• additional hospital coverage (for example, a private hospital room),
• out-of-country coverage,
• services like physiotherapy, counselling, chiropractic,
• equipment such as eye glasses or orthotics, and
• dental services.

Each plan is different and coverage will vary. In some cases, you may receive a card to present to your pharmacist or healthcare professional up front to cover all or part of your medication or treatment. In other cases, you will have to pay the bill then make a claim to the insurance company. Remember to always get a receipt!

To learn about what your plan has to offer, review the information provided by your employer and the insurance company. Information about your insurance policy may also be found on the insurance company website in a section dedicated to members. In the case of prescription medications, some insurance companies will offer an online tool so you can check if they are covered.

If you are still unsure if your medication is covered by your private insurance plan, call your insurance company before you go to the pharmacy. Or you can ask your pharmacist — many plans have a web-based service that tells the pharmacist how much is covered and how much you will need to pay.

If you do not have access to a group benefit plan, it is possible to buy an individual or family health plan. Consult an insurance broker for more details and keep in mind that you can sometimes access an insurance plan through an association or group like the Canadian Association for Retired Persons or the Canadian Automobile Association. This gives you the advantage of a better rate, as the costs are shared over a larger number of plan members.

Coordinating your benefits coverage

If you are covered by more than one benefit plan, you may be able to further minimize the amount you pay. This most often occurs when you and your spouse each have a plan, or when a child is covered by a parental plan, but also has a work plan.

Though coordinating benefits can sometimes be tricky to figure out, reviewing your plans can help you decide which benefit plan to submit to first. Whatever portion is left unpaid may be claimed through the second insurer.

You may find that one insurer won’t cover a medication or treatment, but another will. Or you may reach the maximum amount you can claim with one company, but be able to claim further expenses from the second.

Whether you’re researching your region’s health plan or trying to understand your workplace health insurance forms, it can seem like they’re written in a different language. Here are some key terms and concepts to help you make sense of it.

Formulary

A formulary is the list of prescription medications or products that are covered under an insurance plan. The federal, provincial and territorial governments participate together in a process called the Common Drug Review. An expert committee evaluates new drugs and gives evidence-based recommendations about which should be covered by public drug benefit plans. Often private insurance plans base their formularies on the public plan formulary in their jurisdiction.

Generic Substitution

When a drug is first introduced, it is usually patented by the drug company that developed it. This means that for a period of time, only they can manufacture and sell it.

When the patent expires, other companies can produce generic versions of the drug. Generic versions of a drug contain the same active ingredients as the brand name drug, but typically cost less. Many benefit plans (public and private) require the pharmacist to provide you with the least expensive version of the drug, regardless of what was written on your prescription.

There can sometimes be differences between the name brand and generic versions of drugs. If the generic product has not worked for you, your physician can indicate “no substitution” on your prescription. The difference in cost may be covered by your plan, or you may be required to pay for it yourself. Sometimes an insurance company will require your doctor to present medical evidence as to why you require the non-generic version of a drug.

Benefit

The payment made by an insurance company after approving a claim.

Claim

A formal request to the insurance company for payment of a benefit.

Co-insurance

An arrangement in a health insurance plan where you and the insurance company share the cost of the items covered. You usually pay a set percentage (for example, 20 per cent) and the remainder (80 per cent) is paid by the insurance plan.

Co-payment or Co-pay

A predetermined fee a plan member pays for healthcare services. This amount is usually a flat fee.

Deductible

The amount that plan members have to pay before the insurance kicks in. For example, you might have an annual $500 deductible, meaning you cover the first $500 for health services before your insurance company begins to pay. There may also be a set deductible for each prescription drug.

Premium

A fee paid to the insurance company or health plan to provide insurance coverage. Depending on your type of plan, this may be paid, all or in part, by a third party such as your employer.

Plan Member Payments

Additional costs that you, the plan member, may have to pay. If you are part of a health insurance plan, whether public, private or individual, there are likely additional costs you'll have to pay when you make a claim or seek reimbursement for a benefit.

If your private health insurance plan doesn't cover your needed treatment, you may decide to advocate for further coverage under your plan. The following steps may be helpful when advocating for the coverage you need:

Gather Necessary Information

Make sure you know your benefits policy number, employer's name/policy number, and your physician's phone number. If you are requesting specific medication, find the drug identification number (DIN) — your doctor can give this to you or you can find it on Health Canada’s website.

Keep Your Plan Sponsor Informed

If your insurance plan is through your workplace, let your Human Resources Manager know what the insurance company told you and explain that your physician considers this treatment vital to your health and well-being. If your plan’s sponsor is a union or association, call your representative and let them know what’s happening. They may have had others in the same situation and might be able to help.

Make the Call

Call your insurance company's benefits department to confirm that they do not cover the treatment. Ask them why. You could also ask your doctor to call them for you. Determine if the insurance company excludes this particular treatment from all of its plans, or if the exclusion is specific to the level of plan you have. If it’s the latter, a plan sponsor has the option of making an exception. You can advocate with your plan sponsor to have your treatment covered.

If the insurance company will not cover the specific treatment you need, have your physician write a letter of appeal, giving the reasons why you need this treatment. If the appeal is rejected, you can contact the insurance company's ombudsperson to file a complaint and request reversal of their decision.

Consult With Others

If you are part of a patient support group, discussion board or chat room, ask if others have experienced something similar. Did they have any success? What approaches would they recommend? If you aren’t yet part of a group, you may want to look into local or online communities of other people with arthritis.

The Arthritis Society’s mission includes the important goal of ensuring people have access to timely and effective care. Connect with the Arthritis Society to see if you can play a role their ongoing advocacy initiatives with other critical volunteers.

Beyond private insurance, you may be able to access additional funding to offset your healthcare costs. Some of these additional sources of funding include the following. For further details, download the Additional Medical Coverage Sources.

• Workers’ Safety and Insurance Board/Workers’ Compensation Board
• Provincial Compassionate Care Programs
• Provincial Exceptional Access Programs
• Pharmaceutical Company Compassionate Programs
• Patient Support Programs
• Medication Reimbursement Specialists
• Tax Credits