Part 1: Helping Employees Address Gaps in Health Services

This is the first of a two-part series that discusses challenges and solutions around addressing gaps in health care services.

Canada’s publicly funded healthcare system offers many benefits, especially when compared to the coverage that our American neighbours have. Unfortunately, this comparison has lead Canadians to overlook the flaws in our own plans.

Gaps in Medicare include the lack of a national pharmacare program, differences in treatments and coverage offered by each territory and province, and a failure to integrate complementary medicine.

The result of these gaps has led to “a comparatively higher infant mortality rate, the prevalence of chronic conditions, long wait times in emergency rooms and to see specialists, poor availability of after-hours care, and unreliable coverage for things like dental work and many prescription drugs.”  

This is the bad news, but the good news is there are steps that can be taken by employers to help fill the voids.

Addressing the Gaps in Health Coverage: Where to Start

In order to understand where the gaps lie, we first need to review the available coverage:

1. Medicare – provincial or territorial coverage based on residency. The Canada Health Act outlines the types of coverage which each provincial or territorial plan must offer.

General categories include in-hospital care, doctor’s visits, and diagnostic services. Some citizens may also be eligible for supplementary benefits based upon income or health. Details of British Columbia’s Medical Services Plan are available on the provincial government website.

2. Provincial Pharmacare – under the Canada Health Act, each province or territory must provide prescription drug coverage.  Coverage between the provinces and territories varies.  In some jurisdictions the amount of reimbursement is tied to income, in others there are several programs from which to choose.

In British Columbia, the program is called Fair Pharmacare. It is the largest program of any of the provincial or territorial plans.  

One challenge to multi-jurisdictional employers of the current system is that a specific course of treatment may be covered in one province but excluded in another.  Formularies – the list of drugs covered by each territory or province – is not consistent, creating inequalities between employees based on their residency.

3. Extended Health Plan – extended health benefits generally include coverage for prescription drugs, paramedical practitioners, out of country coverage, medical supplies, and dental care.  

Coverage is most often available through an employer or association sponsored plan.  However, individual plans are available for people who are self-employed, retired, or simply without coverage.

Extended Health Plans are generally the primary source of reimbursement for prescription drugs and medical supplies, as most Canadians do not reach the prescription drug maximums under their provincial or territorial pharmacare programs.

Additionally, they do not qualify for reimbursement for medical supplies under the supplemental benefits portion of Medicare.

4. Private Healthcare – some individuals pay fees to a private healthcare facility which has opted out of provincial coverage. In this case, the facility bills patients directly. These centres offer integrated healthcare and generally avoid waiting times found in the public system but they come with a hefty price tag. 

However, employees and thus employers must be aware that patients of these facilities need to maintain their Medicare coverage in order to remain eligible for provincial benefits such as in-hospital care, provincial pharmacare and most importantly employer sponsored extended health plans.

All Canadian insurers require employees of an extended health plan to be a member in good standing of their respective provincial or territorial plan.  

5. In-home Care – for individuals who require assistance to remain in their home due to illness, injury, or infirmity, nursing care is available.  Provincial and territorial plans provide some publicly funded assistance.  

For example, community health nurses make in-home visits to new mothers following discharge from the hospital.  Extended health plans generally have an annual allotment for private duty nursing but there are limitations which can result in out of pocket expenses to assist with practical matters such as meals and laundry.

Additional Assistance Employers Can Offer

Employers who wish to help employees address the gaps have several tools available:

• Provincial Pharmacare programs will consider covering prescription medications that are not usually covered by the formulary, on a case by case basis. An experienced benefits advisor can help to initiate the application process.  

• Extended health insurance carriers have developed internal programs to assist plan sponsors and their members to help manage costs on prescription medications which exceed the annual pooling limit.

Your benefits advisor or insurance company can provide details on how to access these programs. Insurance carriers also provide assistance in accessing the best course of treatment to shorten the duration of a condition resulting in a long-term disability claim.  

An experienced advisor can help to ensure that potential disabilities receive intervention and assistance as early as possible.

• Employers can help supplement annual plan limits for expenses such as physical therapy, home care, or medical supplies through the offering of Health Care Spending Accounts (HSA).

• Finally, an employer can review the often overlooked pooled benefits to determine if any changes or enhancements should be considered for short and long term disability coverage, critical illness insurance, or long-term care.

Conclusion

For most Canadians, employer, association or individual extended healthcare plans in combination with provincial or territorial Medicare provide sufficient benefits.

However, for those who experience serious illness, chronic conditions, or require ongoing care, the cost of medications, therapy, or nursing may erode savings or increase debt.  

In part two of this blog series, we will examine how disability, critical illness, and long-term care insurance can provide much needed funds when an employee or family member falls into a healthcare gap.