Extended health care is the most common benefit in employer group plans and is also available as individual coverage. A standard EHC plan reimburses eligible expenses up to the plan maximums after any deductible.
Typical EHC categories:
Prescription drugs: the benefit pays a percentage (often 80 to 100 percent) of eligible drug costs above a deductible, sometimes subject to a formulary. A formulary is an approved list of drugs; drugs not on the formulary require special authorization or are not covered.
Paramedical practitioners: common plan designs reimburse up to a dollar maximum per practitioner per year (e.g., $500 for physiotherapy, $500 for chiropractic) after the provincial plan, if any, has paid. Some plans require that the practitioner be licensed in the province.
Hospital accommodation upgrade: the benefit reimburses the cost of private or semi-private accommodation above the ward rate. The ward rate is covered by provincial insurance; the upgrade premium is covered by the private plan up to the policy maximum.
Medical equipment and supplies: crutches, prosthetics, orthopaedic shoes, hearing aids, and other eligible items may be covered to annual or lifetime maximums.
Out-of-country/out-of-province emergency medical: one of the highest-risk coverage areas. Provincial plans pay only a fraction of hospital costs in the United States. Group and individual EHC plans include emergency travel medical coverage for acute, unexpected illness or injury while temporarily outside the province or country. Most plans require that treatment be for an emergency (not elective) and that the insurer be notified promptly.
Exam note: the distinction between emergency and elective is critical. If a client travels to receive a planned procedure outside Canada, the travel medical benefit almost certainly will not respond.