When people are hurting, every obstacle to treatment is real and seems hard to overcome. Questions about health insurance weigh heavily on people’s minds and fears of the unknown influence treatment choices.
We have had a lot of questions about insurance over the years. I shared some recent concerns with the pros: two women I trust in the financial planning field: Jackie McCann Scott and Michele O’Rielly. Thank you both for your insights.
Here ‘s what you need to know and some questions to ponder to protect your future and your health options.
Did you know…?
Health Insurance was established to offset the cost of the care/therapy/drugs you need. It was never intended to fully cover the costs.
This is particularly true for paraprofessional care (physiotherapy, massage therapy and naturopathic services. In many cases, the extended health benefits covered for these services have not increased for 20-30 years. We know costs have risen dramatically in that time. When you are injured you may need to pay out of pocket for the therapy you require.
Health care is not free! You pay for Medicare services through taxes and you pay for extended health services through your personal or work-related health insurance. It is costly!
Each insurance contract is unique!
Clients may purchase health insurance privately; but more likely they have health insurance through work. Each employer (or individual) negotiates a contract with their insurance provider for extended health coverage that insures medical, drug therapy and paramedical care. Important considerations that are balanced out include: the employees’ needs and willingness to pay. Physiotherapy, massage therapy, acupuncture, naturopathy: the services offered by Avalon Laser are considered paraprofessional (paramedical) services for insurance purposes.
Each person is responsible to confirm their extended health benefits personally. It is highly confidential information.
Check out your insurer’s website!
Most major insurance providers maintain an up-to-date website that manages your personal health insurance plan. Simply go to your provider’s website and register, with your group insurance number and your personal certificate number. Your insurance benefits are laid out clearly on the website. If the internet is not your thing, your provider will offer a handbook that outlines your health benefits.
Insurers have made their websites user friendly. Some services include:
- Find a service (paraprofessionals in your area are usually listed). Need an occupational therapist or physiotherapist? Check the “Find a Service” tab to connect with a skilled therapist in your area.
- Submit a Claim: Most insurers have made getting your payments quickly a priority. You should be able to upload a picture of your receipt (doctor referral if required) online, submit the receipt and receive payment in your bank account in 24-48 hours.
- Benefit Summary: will outline the benefits covered under your plan.
- Claims Information: will track the benefits you have received to date.
Does your policy have a deductible?
Sometimes an insurer will require that the insured pay a deductible of a set amount $100 (or more) before the insured is able to access insurance services.
Do you need a medical referral?
Few insurances require a referral from your doctor for physiotherapy, chiropractic or naturopathic care. Many do for massage therapy, podiatry, and occupational therapy among others. If you are not sure, we recommend that you check with your insurance provider.
What is your co-pay?
The co-pay is your share of the treatment cost. We most often see the 80/20% split between the insurer and the insured. In this instance the amount the client has to pay as co-pay is 20%.
There are other splits 70/30% and for some, insurers even cover 100% of the costs for services.
What about Direct Billing?
Many health services can be direct-billed from your health clinic to your insurance provider. Where this is feasible, fees for services will be charged directly to your insurance and you will only pay the co-pay for your treatments.
How much coverage do you have really?
It all depends on the contract! Most insurance providers offer an 80/20% split on drugs and paraprofessional services. Insurance providers pay for services rendered according to the employer contract. Here are some examples of different reimbursement systems: In these examples, the insured has the “standard” $500 of insurance coverage with an 80/20 split.
- 80% of the total amount ($500) is insured. The insurer will pay $400 in benefits and the insured will pay the $100 co-pay.
- 80% up to the insured amount of $500. In this instance the insurer will pay up to $500 in benefits. If all benefits are used, the client will pay $125 and will receive up to $625 insured paraprofessional services.
- 100% covered up to the maximum insured value of $500. No co-pay.
- The insurer will cover 80% up to the maximum of $500; but has set a cap on the cost of treatments. As an example, the insurer might cover $60 of a $70 physiotherapy treatment. The client will need to pay $10 plus the relevant co-pay for each treatment. With the capped plan, the insured would receive $500 in benefits but would pay up to $200 ($70 of amount excluded + $126 in co-pay plus the $4 left over)
The point is that you really have to ask your insurance provider how your insurance benefits are covered to understand the reimbursement plan.
Here come the surprises… really worth considering!
What if you lose your job and are no longer covered by insurance?
Loss of insurance is a huge concern. If you lose a job, you may be with out insurance until you find another job. If you have a pre-existing condition like diabetes or sciatica, you may be denied coverage for these conditions.
There are a couple of options for people who change jobs often or who require uninterrupted insurance for health reasons.
One is to take control of your own health from the get-go. Establish your own health insurance plan. This secondary coverage protects one from the swings of the workplace.
The second, recent option is the Blue Cross Assured Access Plan. Under this plan, one initially applies to be accepted into the program. Then one becomes “pre-approved” for insurance coverage. For a modest fee (may be as low as $20 monthly) this insurance enables one to access insurance during the periods you may be withfxdxxout work and ensures that you will not be penalized for pre-existing conditions.
Given the changes in the workforce, this is a valuable option for many! If you are entering the work force, consider this option carefully. Did you know… the average Canadian worker will hold about 15 jobs in their career? ** The transitions between jobs may leave you or your family without insurance coverage. It is easiest to protect yourself when you are young and healthy!
What happens when you reach retirement?
I was surprised to learn that an employer is not required by law to offer insurance after retirement. Some do; but there is no obligation on the employer. For this reason, many people find themselves facing retirement and looking for an insurance plan to meet their needs at the worst possible time. If there are pre-existing health conditions, the soon-to-be retiree may be unable to access insurance at a rate that is affordable. It is important to plan your health insurance along with your retirement finances for a safe and healthy future.
An option for business owners:
There is a third option for business owners. Cost Plus is a tax-deductible insurance business owners can purchase for themselves and for their employees. It is a tax-free benefit and offers a way small business owners can support their employees (or their own) health needs without investing in a fixed insurance plan, or in addition to a group insurance plan. For a fee, Cost plus delivers a specific amount to the party (employee or employer) that can be used towards health costs or needs. Cost Plus insurance was designed for the needs of small businesses. We recommend business owners interested to consult with a trusted insurance agent if this option is of interest to you..
I would like to thank two business women I work with for their help answering your questions:
Jackie McCann-Scott of Invested Mama Click here
Michele O’Rielly of MOR Financial Click here
I hope we were able to address your concerns and help find options to protect your own future.
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