Deciding to buy health insurance is not necessarily a straightforward process. In Canada our provincial health care (OHIP in Ontario) covers many services such as hospital and doctor visits, and many medical tests. However, there are many health care services that aren’t covered. So talking to a health insurance company to see about supplementing your Ontario coverage is a smart thing to do. It can protect you and your family from the financial burdens caused by surprise medical care.
Here are some good questions to ask, to get you started.
Am I Eligible for Health Insurance?
This is a good place to start. If you’re not eligible, the rest of the questions are moot. Not everyone will qualify for health insurance coverage. Usually it’s because of the health of the applicant. Some plans restrict coverage based on age, and others require you to have a group health plan. There are some that provide guaranteed acceptance; this means everyone is eligible. However, you’ll pay extra for this.
There is one eligibility requirement for all private health insurance plans in Canada: you have to have a health card in the province where you live.
What is the Cost of Health Insurance?
This is an obvious question, unfortunately with a complicated answer. People often think of monthly premiums, but there are other costs you may incur. Health insurance plans may also have deductibles, copayments and coinsurance. These have to be paid for services you receive.
Types of health insurance costs:
- Premium: This is the basic monthly amount you pay to keep your health care coverage. It’s the same every month.
- Deductible: This is how much you’ll have to pay for services that are covered, before the health insurance starts paying.
- Copayment: This is a fixed cost for a covered service.
- Coinsurance: This is a percentage of the price of a covered service. This is incurred after you’ve reached your deductible.
Because some of these costs are only incurred when you have medical needs, it’s hard to estimate a total. A health insurance agent can help you factor all of these costs in so you can ensure you’ve budgeted enough.
Are Pre-Existing Conditions Covered?
Sometimes you have a pre-existing medical condition at the time you’re shopping for health insurance. Find out if you’ll be covered! If it isn’t you may still have to pay for all of the services necessary to treat it.
If you have a pre-existing medical condition:
- Some plans may charge you higher premiums.
- Some plans may limit how much coverage they’ll provide for them.
- You may have to complete a medical questionnaire before you enrol in the plan. This will assess your health and determine if you qualify for coverage.
Take extra care if you have pre-existing conditions. Read the policy carefully so you know what you’ll be responsible for. And don’t try to hide a pre-existing condition. The insurance company can decline to provide coverage and your whole policy could be void. Talk to a health insurance agent if you have questions.
What is the Most the Health Insurance Plan Will Pay Out?
This is called the plan maximum and most health insurance plans have them. It refers to the highest dollar amount the plan will cover for a specific service(s) in a given time period. The insurance company will stop paying when the plan maximum for a particular service is reached. You’ll be responsible for paying additional costs.
In addition to service maximums, some health insurance plans have lifetime maximums. This is defined as the highest amount the plan will pay over your lifetime, for all covered services. You’ll have to pay all future medical expenses after you reach the lifetime maximum.
How to select the right health insurance maximum:
- Look at different health plans and compare. Some plans have higher maximums than others.
- Think about your current health and how it may change in the future. If you have a pre-existing condition and expect to use insurance more frequently, a higher maximum is a good idea.
- Perhaps you don’t have any existing health issues, but due to genetics or another reason you are concerned that your medical costs will be high. You’ll appreciate the peace of mind higher maximums could provide.
What is Not Covered by the Health Insurance Plan?
No plan is going to cover everything, so it’s a good idea to understand what costs you’ll be responsible for.
Typical exclusions from health insurance plans:
- Fees that are higher than usual, or what’s reasonable, and ordinarily charged in your area
- Supplies, services, and equipment that may be incurred while in a in long-term care facility
- Things that are already covered by OHIP (or your province’s health plan) or by a pharmaceutical manufacturer’s assistance program
- Replacement or duplicate prosthetic devices or durable medical equipment (unless your condition has changed, or the existing item is in disrepair)
- Supplies or services because of injuries or illness that resulted from war, while serving in the armed forces, or participating in a civil commotion or riot
- Medical care necessitated by intentional self-inflicted injuries
- Injuries that happen while committing or attempting to commit a crime
- Prescription drugs, supplies or services that have been self-prescribed or prescribed by or for a family member
- Charges incurred due to missed appointments, or to fill out claim forms
- Experimental drugs, tests, treatments, or supplies that are not medically necessary
- Aesthetic or cosmetic (this does not include reconstructive surgery to repair tissue damage caused by injury or disease)
Your Ontario Blue Cross Agent Can Help
Selecting the right health insurance plan for you and your family is not a quick decision. There are many things to consider. Learn more about our Blue Cross health insurance plans for Ontarians. Give us a call if you have any questions: 1-866-848-8836.