Health Insurance – Understanding What It Covers
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What are “covered services”?
Your health insurance policy is an agreement between you and your insurance company. The policy lists a package of medical benefits such as tests, drugs and treatment services. The insurance company agrees to cover the cost of certain benefits listed in your policy. These are called “covered services.”
Your policy also lists the kinds of services that are not covered by your insurance company. You have to pay for any uncovered medical care that you receive.
How do I know which services are covered?
If you already have an insurance plan and want to keep it, review your benefits to see which services are covered. Your plan may not cover the same services that you would receive if you signed up for a new plan with a different employer.
Essential Health Benefits
Healthcare in Canada is funded by the federal government and provided by the individual provinces and territories. The Canada Health Act sets out the conditions under which that care will be provided.
All necessary services including hospitals, physicians and surgical dentists must be insured. Private health insurance supplements primary provincial health coverage.
Services deemed non-essential and thus not covered by provincial health insurance include preferred hospital accommodation (unless prescribed by a healthcare provider), private duty nursing services, and telephone/television services while in hospital. Some uninsured healthcare provider services include telephone prescription renewals, medical certificates, and cosmetic services.
What is a medical necessity? Is that different from a covered service?
Keep in mind that a medical necessity is not the same as a medical benefit. When a service provided to a patient is medically necessary, it is fully funded by the government and delivered based on the patient’s need, not their ability to pay. A medical benefit is something that your insurance plan has agreed to cover. In some cases, your healthcare provider might decide that you need medical care that is not covered by your insurance policy.
What should I do?
There are so many different insurance plans that it’s not possible for your healthcare provider to know the specific details of each plan.
By understanding your insurance coverage, you can help your healthcare provider recommend medical care that is covered in your plan.
- Take the time to read your insurance policy.
- If you still have questions about your coverage, call your insurance company and ask a representative to explain it.
- Remember that your insurance company, not your healthcare provider, makes decisions about what will be paid for and what will not.
What happens if my healthcare provider recommends care that isn’t covered by my insurance?
Most of the things your healthcare provider recommends will be covered by the province or your plan, but some may not. When you have a treatment that isn’t covered, or you get a prescription filled for a drug that isn’t covered, your insurance company won’t pay the bill. You can still obtain the treatment your healthcare provider recommended, but you will have to pay for it yourself.
If your insurance company denies your claim, you have the right to appeal (challenge) the decision. Before you decide to appeal, know your insurance company’s appeal process. This should be discussed in your plan handbook.
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