Health and dental coverage

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No price appears on this page, and none is sent by email. What a contract costs depends on the person and the design, and no honest figure can be produced from three answers.

What a provincial plan leaves you

• Hospital and physician care is covered everywhereThat is the common floor across Canada. The gaps are what sits outside it.
• Dental is outside the public plan almost everywhereSome provinces cover children or specific surgical procedures. Routine adult dental care is generally not covered.
• Prescriptions depend on where you liveQuebec requires everyone to be covered by a drug plan, public or private. Most other provinces cover drugs only for certain ages, incomes or conditions.
• Travel outside your province is the largest gapA provincial plan pays a fraction of what care costs elsewhere, and often nothing at all outside Canada.

What individual health and dental insurance actually is

Individual health and dental insurance is coverage a person buys for themselves and their household, directly from an insurer, to pay for health costs the provincial plan does not pay. The list of costs is familiar to anybody who has ever had an employer plan: prescriptions, dental work, glasses, a physiotherapist, a psychologist, a hearing aid, a wheelchair.

The difference is structural rather than medical. Under an employer plan the cost is shared with an employer and the risk is pooled across everybody who works there, which is why a group plan can accept a person with a serious condition without asking a single question. On an individual plan there is no employer and no pool of colleagues. The insurer is looking at one household, and everything that follows on this page comes out of that fact.

People arrive at this product from four directions. The self employed person who has never had a plan. The contractor whose contract does not include one. The retiree whose employer coverage ended on the last day of work. The person between jobs who has discovered what a month of prescriptions costs when nobody is paying a share of it.

It is worth saying plainly at the top what this coverage is and is not. It is not medical care and it does not get anybody seen faster. It is not income protection. It is a contract that pays part of a bill for a defined list of goods and services, up to defined ceilings, for as long as the premium is paid. For some households that is genuinely valuable and for others it is an expensive way to pay for something they were already paying for, and this page is written to let a reader tell which one they are.

What the provincial plan already pays, and what it does not

Every province and territory covers medically necessary physician services and hospital care for its residents. A visit to a family doctor, a specialist consultation, surgery, a night in a ward, the drugs administered to a patient while they are actually in hospital: those sit inside the public plan and an individual health plan is not needed for them.

What sits outside the public plan is the part that surprises people, because it is most of ordinary life. Prescription drugs filled at a pharmacy are generally outside it for a working age adult in most of the country. Routine dental care is outside it almost everywhere. Eye examinations for adults, glasses and contact lenses are largely outside it. So are physiotherapy, massage therapy, chiropractic care, psychology and the other paramedical services, except in narrow circumstances. So is an ambulance, in most provinces. So is a private or semi private hospital room. So are crutches, a brace, a hearing aid, a breathing machine and most other equipment a person takes home.

Public drug coverage in particular differs by province, and it differs more than most people assume. Some provinces run an income tested public drug program that anyone can register for. Some cover seniors, or people on social assistance, or children, and leave the working age adult to arrange their own. Quebec is different from all of them in a way that changes how an individual plan is built there, and the French version of this page sets that out.

The practical instruction is the same everywhere. Before buying anything, read what your own province actually covers, on the province’s own health plan website, because the answer decides how much of this product you need and because it changes. Nothing on this page is a statement of what your province pays today.

The categories a plan is built from

An individual health plan is not one thing. It is a set of separate buckets, each with its own ceiling, its own share of the bill and sometimes its own waiting period. Reading a plan means reading the buckets, not the headline.

Prescription drugs. Usually the largest bucket and the one that carries most of the genuine insurance. A plan pays a share of each eligible prescription rather than all of it, up to an annual ceiling, and it pays only for drugs on the plan’s own list. Two plans that both say they cover drugs can behave very differently once a household needs an expensive one.

Dental. Normally split into basic care, which means examinations, cleanings, fillings and extractions, and major care, which means crowns, bridges, dentures and root work. The two halves have different shares and different ceilings, and major care is where the waiting periods live. Orthodontic coverage, where it exists at all, is a third bucket again with its own lifetime ceiling.

Vision. An eye examination on a stated cycle and an allowance toward glasses or lenses over a stated period. This bucket is small in almost every plan and it is the one people most often overestimate.

Paramedical practitioners. Physiotherapy, chiropractic care, massage therapy, psychology, naturopathy, podiatry, speech therapy and others, each with a ceiling per practitioner type per year and often a cap per visit as well. Read which practitioners are on the list, because the list differs and the one a household actually uses may not be on it.

Hospital accommodation, medical equipment and supplies, and travel emergency medical coverage make up the rest. The travel benefit included in a health plan is real coverage and is worth knowing about, and it is also usually shorter and narrower than a policy bought for the trip itself, which is the subject of our page on travel insurance.

Two doors: guaranteed acceptance and medical underwriting

Individual plans are sold through two entirely different doors, and which door a household is eligible for decides almost everything about what it can buy.

A medically underwritten plan asks health questions. The insurer reviews the answers and then decides whether to issue the plan, and on what terms. It may issue it as applied for. It may issue it with an exclusion attached to a condition the household already has. It may charge more. It may decline. In exchange for that assessment, the plan generally has higher ceilings, a wider drug list and better dental coverage, because the insurer knows what it has accepted.

A guaranteed acceptance plan asks nothing, or almost nothing. Anybody within the eligible ages is issued a plan. Because the insurer cannot assess anybody, it protects itself in the contract instead: lower ceilings, a narrower list of covered drugs, longer waiting periods before the larger benefits become available, and in many contracts a period at the start during which a condition the person already had is not covered at all.

That last point deserves care, because it is the one that generates disappointment. Guaranteed acceptance does not mean guaranteed payment. It means guaranteed issue. A household that enrols in a guaranteed acceptance plan specifically to cover a condition it already has should read the pre existing condition wording before the first premium, not after the first claim.

Neither door is better than the other in the abstract. A household in ordinary health that can answer the questions has access to more coverage through the underwritten door. A household that cannot has the other door, and coverage with limits is not the same thing as no coverage.

The window after an employer plan ends, and why it closes

This is the section that changes outcomes, and it is the one most people read too late.

When group coverage ends, whether through a layoff, a resignation or retirement, most group contracts carry a conversion privilege. It allows the departing member to move to an individual plan with the same insurer without answering medical questions. No questionnaire, no exclusion attached to an existing condition, no decline. It is the same person walking through the underwritten door without being underwritten.

The privilege is time limited. The window opens on the day the group coverage ends and it closes a short time later, and the length is set by the group contract rather than by law, which means it has to be read rather than assumed. Miss it and the conversion right is gone permanently. What remains is a fresh application with full health questions, at whatever age and in whatever health the person has by then.

For a household in good health the loss is usually modest, because full underwriting is likely to produce a plan anyway. For a household where somebody has a diagnosis, an ongoing prescription or a recent hospital stay, the difference between converting inside the window and applying outside it can be the difference between a plan with real drug coverage and a plan with an exclusion on the exact condition the family needed covered.

The practical step is small and it has a deadline. Ask the employer or the plan administrator, in writing, on or before the last day of coverage, two questions: does this group contract have a conversion privilege, and by what date must it be exercised. Put the date in a calendar. Severance arrangements that continue benefits for a period do not always extend that date, so confirm which date the clock actually runs from.

Annual maximums, and the day they reset

Almost every benefit in a health plan is capped. There is normally a ceiling per category per year, sometimes a ceiling per visit or per item inside that, sometimes a combined ceiling across several categories, and on a few benefits a lifetime ceiling that never refills.

The ceilings reset, and the date they reset on is worth knowing before a household needs it. Some plans reset on the calendar year and some on the policy anniversary, which is the date the plan started. A family planning dental work that will exceed one year of ceiling can often have part of it done before the reset and part after, which is an ordinary and legitimate way to use the contract, and it only works if somebody knows the date.

Unused ceiling does not usually carry forward. A household that claimed nothing this year begins the next year with the same ceiling, not a larger one. The plan is not a savings account and nothing accumulates in it.

One more mechanism that changes the arithmetic. Many plans pay a share of an eligible expense rather than the whole of it, and the share can differ by category, so basic dental and major dental are frequently paid at different rates. A plan can therefore reach its ceiling while the household has still paid a meaningful part of every bill along the way. Both numbers, the share and the ceiling, are printed in the contract, and reading only one of them produces a wrong expectation.

Waiting periods, and why major dental has the longest one

A waiting period is a stretch of time after the plan starts during which a benefit is not yet available. The plan is in force, the premium is being paid, and that particular benefit simply cannot be claimed yet.

Basic dental usually has a short waiting period or none. Major dental usually has a long one. Orthodontic coverage, where it exists, generally has the longest of all. The reason is not administrative. It is that a person who knows a crown is coming can buy a plan the week before, and if the benefit were available immediately, everybody would buy the plan the week before and the benefit would cost more than it collects.

The same logic explains why guaranteed acceptance plans have longer waiting periods than underwritten ones. The underwritten plan protects itself with questions. The plan that asks no questions protects itself with time.

The consequence for a household is a matter of order. Buying a plan in order to pay for dental work that has already been recommended usually does not work, because the work will fall inside the waiting period. Buying a plan while nothing is wrong is the only way the major benefits are available on the day something is. That is an uncomfortable thing to read for somebody who came to this page because of a bill they already have, and it is better read here than discovered after the first premium.

The honest arithmetic, stated once

Insurance is worth buying when the loss it covers is larger than a household can absorb. A plan whose yearly premium is close to or greater than the total it could ever pay out in a year is not doing that job. It is a payment plan for expenses the household was going to have anyway, with an administrative cost on top and a set of rules about which dentist and which drug.

That is not an accusation against any particular plan. It is arithmetic that any reader can do in ten minutes with the contract in front of them. Add the annual premium. Add the ceilings the household would realistically reach, which is not the same as the ceilings printed, since almost nobody reaches all of them in the same year. Apply the share the plan pays. Compare.

Where the comparison usually turns is prescription drugs. Dental, vision and paramedical costs are annoying but they are broadly predictable and broadly affordable, which is why plans built mostly out of those three often come out as budgeting rather than insurance. Drug costs are not predictable. A single new diagnosis can produce a prescription that costs more in a year than everything else on the plan combined, and that is the risk a household cannot absorb and cannot see coming.

So the useful question is not whether the plan pays for the cleaning. It is what this plan does on the day somebody in the house is prescribed something expensive: how large the drug ceiling is, what share is paid, whether the drug list is broad or narrow, and whether there is a cap that stops the coverage exactly when it would start to matter.

A household that reaches the end of that arithmetic and finds the plan is buying budgeting rather than insurance has not wasted its time. Budgeting has value for a household that finds a predictable monthly amount easier to carry than an unpredictable annual one. It is simply worth knowing which of the two is being bought.

The plan types beside one another

Four arrangements get described as health coverage in ordinary conversation, and they behave differently on every question that eventually matters.

The line worth carrying away from the table: a group plan and an individual plan can look identical on a benefits summary and be completely different instruments, because one of them accepted the member without asking anything and the other one asked, or protected itself another way.

What this coverage is not

It is not income protection. A health plan pays part of a bill. It pays nothing at all if the reason the household is in trouble is that somebody stopped earning, which is the subject of disability insurance and the single most common gap for a self employed person who has just bought a health plan and believes they are covered.

It is not coverage for a serious diagnosis. A health plan will help with the prescriptions after a cancer diagnosis and it will do nothing about the months of reduced income, the travel to treatment, or the spouse who takes leave to provide care. That is what critical illness insurance is built for, and it pays a lump sum on diagnosis rather than reimbursing receipts.

It is not coverage for long term care. Help with dressing, bathing, eating and moving, whether at home or in a facility, is outside a health plan and outside most of what the public system funds, and it is the subject of long term care insurance.

And it is not life insurance. A household that has arranged health and dental coverage and nothing else has arranged for the smaller of its exposures. What happens to the people who depend on an earner if that earner dies is answered by term life insurance or whole life insurance, and by neither of them accidentally.

The households this fits, and the households it does not

It fits a household with ongoing prescription costs and no group plan. That is the case where the coverage is doing genuine insurance work rather than smoothing a bill, and it is the case where the drug bucket is worth reading line by line.

It fits a household leaving a group plan inside the conversion window, particularly where somebody in it would not pass full underwriting. The window is a right that expires, and letting it expire converts an easy decision into a hard one.

It fits a self employed household that wants a predictable monthly amount instead of an unpredictable annual one, provided the household knows that is what it is buying.

It fits less well where the household is young, healthy, has no prescriptions and visits a dentist twice a year. There the arithmetic in this page tends to come out against the plan, and the same money left in the household covers the same cleanings with no rules attached to it.

And it fits badly as an answer to a bill that already exists. Waiting periods and pre existing condition wording are designed precisely to prevent that use, and a plan bought for that reason usually disappoints.

The mistakes this page exists to prevent

Letting the conversion window close. It is the only moment when an individual plan is available without health questions, and the date is in the group contract rather than in anybody’s memory.

Reading the headline instead of the buckets. A plan is a set of separate ceilings and shares, and the summary page is not the contract.

Assuming guaranteed acceptance means guaranteed payment. It means guaranteed issue, and the protection the insurer could not take through questions it takes through waiting periods and pre existing condition wording.

Buying a plan to pay for work already recommended. Major dental waiting periods exist to stop exactly that, and they generally do.

Comparing plans on premium alone while ignoring the drug ceiling and the drug list, which is where the only unpredictable cost in the whole contract lives.

Arranging health and dental coverage and calling the household protected, while nothing at all is in place for a lost income, a serious diagnosis or a death.

Questions people ask

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