Six Things You Need to Understand About Your Health Insurance Plan

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To choose the health insurance plan that best meets your needs, it’s important that you understand the key terms you will encounter during your health insurance search.

Supplemental health insurance plans can be invaluable to individuals and families who need additional coverage not offered under their provincial insurance plans. But health insurance does not come in a one-size-fits-all solution. So how do you choose?

There are many different plans available in the marketplace today that provide varying levels of protection for a wide range of products and services.

Here are six key terms you should understand when trying to find a health insurance plan that’s right for you and your family.

1. What Is Covered Under Extended Health Benefits?

Extended health benefits are the products and services covered under a supplemental health plan other than prescription drug and dental expenses. These are healthcare services not covered under provincial insurance plans and may include

  • vision care
  • ambulance transportation
  • hearing aids
  • home support services
  • emergency medical travel coverage
  • medical equipment
  • registered specialists and therapists, and more.

The level of protection that is offered varies greatly from plan to plan, so it’s important to keep this in mind when shopping for health insurance.

2. Do I have a Pre-Existing Condition?

A pre-existing condition is a medical condition you have been diagnosed with before you apply for coverage, such as diabetes or high blood pressure that requires treatment to manage. If you have a pre-existing condition

  • You may not qualify for some health insurance plans because of your medical condition
  • Your plan may have certain coverage exclusions
  • You may need to look for “guaranteed issue” plans that accept all applicants regardless of their medical history.

If you are losing your group benefits and apply for specially designed individual health insurance coverage within 90 days, you qualify for the plan regardless of your health conditions.

3. What is Medical Underwriting?

This is the process used to determine an applicant’s eligibility for a particular health insurance plan. Not all insurance plans involve medical underwriting, but those that do require applicants to complete a medical questionnaire and/or submit medical information before they will make a determination about whether or not an applicant qualifies for coverage under their plan, or if certain conditions will be excluded from coverage. (see Pre-Existing Condition above)

4. What are Plan Maximums?

Health insurance plans will not pay an unlimited amount of money for treatment. The plan maximum is the highest dollar amount that will be paid out in a given time period (usually a calendar or benefit year) for certain services for each person covered under the plan. For example, if your plan has a maximum of $2,500 per year for home support services, you will be responsible for covering any costs above that amount in that particular year.

Unlike cell phone minutes, maximums do not carry over to the next year if they’re not used. So if your plan will pay up to $1000, that amount is for you, and you have a year to use it. If you don’t, that’s fine; it will be $1000 the next year.

5. Is Hospital Accommodation Included?

Some health plans have semi-private or private hospital benefits included, while others do not. If the plan you are applying for does not include hospital accommodations, you may be able to add that as an extra hospital benefit if you pay an additional premium.

Plans that offer hospital accommodations pay the difference in cost between the standard accommodations covered by your provincial plan and a semi-private or private hospital room up to a maximum dollar amount (typically $150-$250 every day).

6. How Much Does My Health Insurance Cost?

Together, your premium and co-payments/co-insurance make up your total health insurance costs.

  • Your premium is the amount you must pay to your insurance carrier every month to maintain coverage.
  • Co-insurance (or co-payment) is the amount you are required to pay for each visit to a healthcare service provider.

Health insurance plans with higher co-payments tend to have lower premiums, while those with low co-payments have higher premiums.

Need to understand other health insurance terms?

If you want to understand more about health insurance terms, always check SBIS Resources and type in the term you are looking for. You’ll find great information. Still more questions? Call us. At SBIS, we are always happy to help.

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