How much do you know?
If you and your partner both have employee health and dental benefits through your employers’ group plan, can you cancel one of the plans to save money?
Ontarians already pay into the government-funded Ontario Health Insurance Plan (OHIP), and this is often sufficient to cover most basic medical needs. For those expenses that are not covered by OHIP, you may have supplementary health and dental insurance through an employer-sponsored supplementary health insurance plan (group insurance), or you may choose to purchase individual supplementary health and dental insurance to meet your needs.
Group Insurance (Through an Employer or Association)
Group insurance covers all members of a specific group and their eligible dependants. It is often offered through an employee benefits package or through membership in a professional association. You may have your own benefits, or you may be covered under a parent’s or spouse/partner’s benefits. It is important to note that group insurance usually covers the same benefits regardless of the individual and typically cannot be personalized.
If your employer doesn’t offer group insurance, you may be able to purchase it through a professional association or an alumni association.
If your employer offers supplementary health and/or dental insurance as part of a benefits package, they will sometimes pay the
premiums. If you have group insurance through an association, you will have to pay premiums yourself.
What is covered?
Your employer or benefits administrator will provide you with a booklet which outlines your benefits. Most group insurance plans will cover some combination of the following benefits:
- Prescription drugs/medicines
- Semi-private or private hospital rooms
- Special nursing services
- Ambulance services
- Medical expenses incurred outside of Ontario
- Artificial limbs, prostheses and medical appliances
- Wheelchairs and other equipment
- Specified medical services that are not covered by OHIP (chiropractors, physiotherapists, podiatrists, osteopaths, optometrists, massage therapists)
- Vision care (eyeglasses and contact lenses)
- Dental care
Group insurance plans are designed to offer coverage to members of a particular group – usually a company or an association. Each plan is different, so check with your benefits administrator to see if and when you may be covered. Be aware of these common features of group plans:
- Many group plans do not cover part-time or contract staff. Be sure to ask your employer if you are eligible or how to become so.
- You may have to be employed by that company for a certain amount of time before you receive supplementary health and dental insurance benefits; e.g., one month, or three months.
- If you leave the job or the association, your coverage ends.
- Plans usually cover you, your spouse/ partner, and children under age 18 (or older if they are full-time students, or disabled). Eligibility criteria can vary, so check your plan.
- If you are laid off or downsized, your benefits may continue for a few weeks, and in some cases, you may be able to get replacement coverage if you apply within a certain time period. For more information on replacement coverage and how to get it, contact your benefits administrator or the
OmbudService for Life and Health Insurance (OLHI) .
Some group insurance plans allow members to pick and choose the benefits that meet their needs, and to add or change benefits as their family situation changes. For example, you might add orthodontic coverage for your teenage children, and then cancel it when they’ve outgrown the need. You may be able to make adjustments to your plan when you hit major milestones like getting married, or having kids. If your employer offers a flexible plan (also known as “cafeteria-style”), you should review the options carefully, and speak with your benefits administrator if you have any questions.
Coordination of benefits
If you and your spouse/partner both have group insurance through your employers or associations you may be able to combine your benefits to cover up to 100 per cent of your medical expenses. This is known as
coordinating your benefits. Insurance industry procedures determine which plan pays a claim first, and which one picks up the remaining amount. Your benefits administrator can help you with the claim.
If both partners have group plans, and they are not mandatory, you might want to cancel, or opt out of the plan that provides less generous benefits. Or, take advantage of the ability to coordinate benefits if you are able to do so.
If you don’t have insurance through a group plan, or if you want to increase your insurance to cover specialized needs, you can buy an individual plan from an insurance agent or company. Individual plans cover many of the same expenses that group plans cover (listed above), as well as expenses that are specific to your individual needs.
Know what expenses are excluded from your plan. Individual supplementary health plans often exclude expenses incurred as a result of
pre-exisiting conditions. These include injuries or illnesses that you had before you applied for the insurance coverage. Also excluded are all expenses which are covered by a group plan or OHIP. To learn more about exclusions, read your plan carefully and speak with your insurance agent or company.
Like most group plans, individual plans also feature
maximums, so read the policy carefully before buying it and make sure you understand what you are paying for. Ask your insurance agent or company if you have questions.
Insurance for visitors or returning Ontarians: If you are living in Ontario temporarily, or returning to Ontario after a long absence, you may not yet qualify for OHIP, in which case, you may want to consider supplementary health and dental insurance. Some companies sell insurance to cover medically necessary doctors’ services, hospital services and supplies to visitors or returning Ontarians. Some offer emergency-only coverage, some include semi-private hospital rooms, and some pay for an emergency return home for visitors if you are disabled, or die. Be sure to shop around to find the best premium and coverage for your needs.
You may be interested in...
Supplementary Health and Dental Insurance 101: Getting Started: learn more about the common features of supplementary health and dental insurance plans.
Financial Literacy Portal: your one-stop shop for links to other great financial information.
Shopping for Supplementary Health or Dental Insurance: learn what to look for in a supplementary health and dental insurance policy.
Questions to Ask About Supplementary Health and Dental Insurance: consider these questions to ask your employer, human resources representative, insurance agent or company about your health and dental insurance policy.
Supplementary Health and Dental Insurance Glossary: to better understand common supplementary health and dental insurance terms, refer to this glossary.