FAQ

In Ontario, employees have the choice to maintain their health and dental benefits during Parental or Maternity leave if they were eligible for them while working. Employers are required to continue paying for the benefits they provided before the leave. Employees should also arrange to keep paying their share while they're not working. However, if an employee prefers not to continue their share of the benefits cost during leave, they can waive them and rejoin the plan when they return to work. Ultimately, the decision rests with the employee. It's advisable to have a written agreement signed by both the employer and employee to ensure clarity on the arrangement.

When an employee is on parental leave and a baby is born, the timeline for adding the baby to the group plan as a dependent varies based on the parental decision regarding health and dental benefits. If the parent has chosen to maintain their benefits during parental leave, the baby should be added within 31 days of birth. Conversely, if the parent opts not to continue benefits during parental leave, the baby should be added upon the reinstatement of their health and dental benefits.

If both parents have group benefits, the baby should be added to both of their plans within 31 days of birth. In cases where parents have separate group benefits plans, the general rule is to submit the child's expenses to the plan of the parent whose birthday is closest to January 1st. Any remaining expenses not covered by that parent's plan may then be submitted to the other parent's group benefits plan. This coordination of benefits allows families to effectively manage their health and dental costs.

It is crucial to keep your plan administrator informed about any life changes that may affect your group benefits insurance coverage. These changes include the birth or adoption of a child, marriage, or divorce (along with updating beneficiaries for life insurance) and establishing common-law status (typically after a year of cohabitation, unless a child is born, in which case your partner is automatically eligible). Additionally, if your dependent child is attending college or university, they may be eligible for coverage up to the age of 26. It's important to note that if you don't have a spouse on the plan and your youngest child ages off the plan, you should adjust your coverage status from family to single to save on premium costs.

A drug formulary plays a crucial role in group benefits plans in Ontario. Essentially, it serves as a curated list of medications eligible for coverage under prescription drug plans. Each insurance carrier maintains its own unique formulary, outlining which drugs are covered based on various criteria such as therapeutic advantages, safety standards, necessity, and cost-effectiveness. Drugs not included in the formulary are typically not eligible for reimbursement, although some may require prior authorization for coverage consideration. Additionally, certain formularies enforce mandatory generic substitution, meaning brand-name drugs may not be covered under the plan. These measures help ensure the affordability and sustainability of benefits plans while balancing the needs of plan members with cost considerations.

Yes, you can be registered on each other's group benefits plan through a process called Coordination of Benefits. Coordinating your benefits serves as a backup plan to cover additional expenses not covered by the primary plan. When you're covered as a member under a plan, that plan will always pay first before a plan covering you as a dependent. You should submit the claim to your plan initially. Once you receive the explanation of benefits, you can then submit it to your spouse's plan to receive reimbursement for the amount not covered by yours. Additionally, if either you or your spouse has dependent life insurance, both of you will typically be covered under that policy. This coordination ensures comprehensive coverage and can help alleviate financial burdens associated with healthcare expenses.

If you foresee being unable to return to work before the elimination period outlined in the group benefits booklet, it's advisable to begin the process for an LTD claim. This typically should be initiated 8 to 10 weeks before the claim officially starts. The process involves completing three sets of paperwork: one by the employer, which is then sent to the insurance company by the employer; another by the attending physician; and one by the employee, both of which are sent directly to the insurance company. It's important to note that the employer doesn't require access to your medical details. Once all paperwork is submitted, the employee will be assigned a case worker who will guide them through the procedure, while updates will be provided to the Plan Administrator.

Sometimes, the insurance company reimburses based on "reasonable and customary" amounts, similar to a price guide for dental services. Each insurer has their own set limits. It's a good idea to check with your insurer to know the maximum for a specific service or item. If a service costs more than this limit, you might need to pay the extra amount yourself. This helps keep the insurance plan stable in the long run.