The Patient’s Guide to Extended Health Care Coverage

Patients Extended Health Care Guide cover

Welcome to the patient’s guide to extended health care (EHC) for chiropractic coverage. We produced this resource to help you understand your EHC coverage for chiropractic care.

Many EHC plans cover chiropractic care as a ‘Paramedical service.’ If you and your family have EHC insurance coverage, it likely includes chiropractic care.

This guide consists of two main components:

  • A checklist that you can use to help you understand the important details of your EHC coverage for chiropractic services, and for any devices that your chiropractor may prescribe and/or dispense
  • A list of “frequently asked questions” (FAQs) with detailed responses to common queries and concerns you may have

What is Extended Health Care (EHC) for Chiropractic Coverage?

Privately administered EHC coverage comes in individual and group forms. Group coverage is the most common form. Employers, unions or associations (plan sponsors) typically offer group coverage to unionized or non-unionized employees or association members (plan members). Your compensation package includes EHC, which is an important way to share the costs and risks of illness across groups of people. Self-employed people may purchase individual plans for themselves and their family members.

EHC plans are sometimes called supplementary health or supplementary medical plans because their purpose is to supplement provincial health care coverage. EHC coverage may come in the form of EHC insurance, a Health Spending Account, or a Personal Spending Account. It is an important way people can access health services that the publicly administered Ontario Health Insurance Program (OHIP) or the Workplace Safety and Insurance Board (WSIB) do not cover.

In fact, the OCA commissioned an Environics survey in 2019 that found four out of five chiropractic patients in Ontario pay for their care through private insurance coverage.

Eligible Expenses and Chiropractic Coverage Levels

Insurers often set certain conditions or limitations when they define eligible EHC expenses. Conditions might be things like deductibles, co-payments and/or pre-approvals for products such as Orthotics. Common limitations include annual spending limits, limits on what you can spend on specific health care professionals or products, and limits on the amount of money that can be reimbursed per visit.

Your insurance provider or benefits administrator will make decisions about whether a health care expense is eligible for reimbursement under your specific EHC plan. They’ll also decide whether a benefit is subject to conditions or limitations, based on the language of your benefits contract.

Your plan’s level of coverage for chiropractic services depends on the types of plans your insurance provider offers. It’s also affected by the difficult decisions employers, unions, and workers make about what they can afford and what kind of coverage is most valuable to them.

As a patient and a Plan member, your voice matters. If you have questions or concerns about the level of your chiropractic coverage, you can raise these with your employer, union or association that purchases EHC coverage on your behalf.

When Chiropractic is Covered, Everyone Benefits

Research shows the following economic and patient benefits of chiropractic care:

Employees who access chiropractic care tend to incur fewer costs because they are less likely to be prescribed medications or end up with complex medical procedures.[1]

Manual therapy is a common treatment used by chiropractors. It shows an economic advantage compared to other interventions used for managing spine, muscle or joint  (Musculoskeletal) conditions.[2]

Patients receiving chiropractic care have lower disability recurrences and for shorter durations compared to patients receiving care from other health care professionals.[3]

Patients Extended Health Care Checklist

We recommend you learn about the following details of your insurance coverage before beginning treatment with your chiropractor:

  1. What are my coverage levels? Is there a maximum per profession or an overall maximum for a group of professions (e.g. paramedical)?
  2. Does my policy include a health spending account (HSA) or a personal spending account (PSA)? If so, how much is available?
  3. What are Reasonable and Customary fees, or what is the maximum amount that I can claim per visit?
  4. Will my claim require any co-payments or include any deductibles? If so, how much are they and how often will my insurer apply them? (Note: An insurer usually applies co-payments per visit. However, an insurer generally applies deductibles only once per benefit period.)
  5. What is my benefits renewal period/date? Do my benefits renew annually on January 1, or at some other time?
  6. How much of my coverage have I used so far? How much remains?
  7. Is my spouse or are my other family members covered?
  8. Is Virtual Care (or Telehealth) covered? Are there any terms and conditions of coverage that I should be aware of?

Additional Questions for Orthotics or Other Assistive devices

  1. Does my benefits plan cover the product or device [make, model]?
  2. The cost to the patient for this device is [cost].
    • How much of this cost will my plan cover?
    • Are there any fees, such as deductibles or co-payments, that I may need to pay?
  3. What are the terms and conditions of coverage that I should be aware of?
  4. Do I need Pre-approval?
  5. Do I require a prescription? Will my prescription expire after a certain time?
  6. Under my EHC plan, which health care professionals can prescribe the product or device?
  7. Under my EHC plan, which health care professionals can dispense the product or device?
  8. Do I need to submit any other forms, paperwork or documents to ensure I’m covered?
  9. For orthotics: What casting technique is required?

FAQs

A: For privacy reasons, insurers will not provide the details about your coverage to your chiropractor. You’ll need to get details about your coverage directly from your insurer or from your employee benefits resources.

Your insurance provider makes information available to you in a variety of ways: through your employee portal, mobile applications and through its customer service department, which you can usually reach either by a toll-free telephone number or online chat. When possible, request information from your insurer in writing.

It’s a good idea for you to understand the details of your coverage before your treatment begins. That way you know what your plan will cover and you can plan for any out-of-pocket costs that you may have to pay.

Your chiropractor and their administrative staff are happy to assist you. Here is a checklist to help you know what to ask your insurance provider.

Another option that may be available to you is called a ‘predetermination request,’ which is like an estimate.

If this service is available to you, your chiropractor can submit the cost of a specific treatment or product to a third-party service provider. Your chiropractor will then receive information about whether your plan will cover it. You’ll also receive information about any conditions, co-payments or deductibles that may apply to you.

Through the predetermination process, your chiropractor can save you time.  They can get answers to specific questions about your coverage, without compromising your privacy and patient/chiropractor confidentiality.

A: You can submit your claims in one of three ways:

  • Your chiropractor or other health care professional can submit them directly to your insurance provider on your behalf
  • You can submit them electronically through your insurance provider’s portal
  • You can complete and mail in signed, paper forms with supporting documents to your insurance provider’s claims department

We recommend you contact your insurance provider and ask for details about any supporting documents you need to be reimbursed for products or services you receive. You may require specific documents for certain devices (e.g., orthotics).

It’s important that you check with your insurer before you receive a device. That way, you can ensure you submit the correct information with your claim. Usually, insurers will require, at minimum, a receipt or paid invoice. Your chiropractor will complete the paid invoice for you.

A: Ordinarily, you will need to submit HSA/PSA claims directly to your insurer. Most HSAs define eligible expenses as those that qualify for the Canada Revenue Agency’s (CRA)’s Medical expense tax credit.

You can get details about your coverage directly from your insurer or from your employee benefits resources.

Your insurance provider makes information available to you in a variety of ways. These ways include: through your employee portal, through mobile applications and through its customer service departments, which you can usually reach either by a toll-free telephone number or online chat. When possible, request information from your insurer in writing.

A: Your chiropractor cannot bill for physiotherapy services unless they are a dual registrant of both the College of Chiropractors of Ontario (CCO) and the College of Physiotherapists of Ontario (CPO).

Physiotherapy and chiropractic care are distinct health professions, with scopes of practice governed by law in the province of Ontario. This means that by law, chiropractors and physiotherapists must treat patients within their respective scopes of practice.

Sometimes there is overlap between the scope of practice of two or more health professions. For example, prescribing or supervising exercises is within the scope of practice for chiropractors and physiotherapists. However, this scenario does not mean that a chiropractor is performing physiotherapy.

Like therapeutic exercises, acupuncture is considered a treatment that’s included in several health professions’ scope of practice. This means that your chiropractor can use acupuncture in your treatment if they do so in a manner that’s within their scope of practice.

Whether your insurance company will reimburse the cost of acupuncture your chiropractor administers will depend on its policies. We suggest you ask your insurance provider about your coverage before you receive acupuncture treatments from your chiropractor.

A: Chiropractors’ regulatory college allows them to offer discounts and incentives to you as their patient. However, the practice of giving free products or services with paid services is called an Incentive. Insurance companies do not cover the cost of paid products or services that are bundled in this way.

If you receive free shoes or some other incentive, your insurance company will not reimburse the cost of the product or service that you paid for to receive the shoes (or any other incentives). Even if the incentive is given free of charge, it must still appear on any receipt or invoice that’s submitted to your insurer, with the cost to you clearly displayed as “$0.00.”

The Canadian Life and Health Insurance Association (CLHIA) defines Fraud as submitting “false or misleading information” as part of a benefits claim. This includes submitting incomplete information (e.g. omitting an incentive on a receipt). A finding of fraud or abuse can have serious consequences for patients and health care professionals. For more information on Benefits fraud and abuse, please visit: Fraud is Fraud website.

A: No. Billing services under a name other than that of the person who received those services is benefits fraud. It doesn’t matter that the person does not use their coverage. Making a claim under their name is considered submitting “false or misleading information” to your insurer.

A: No. Some health care professionals may charge patients for missed appointments to compensate for their time. However, these appointments cannot be billed to your insurance company. Extended health care (EHC) benefits are intended to cover the cost of medically necessary products or services. Typically, EHC benefits do not cover the cost of financial penalties.

Beyond the specific instance of billing for missed appointments, health care professionals cannot charge you for visits that did not occur. Submitting a bill to your insurer for a visit that did not occur is benefits fraud.

Likewise, your chiropractor cannot issue payment receipts for amounts that are different than what you paid for the products and/or services you received. Doing this is considered giving your EHC provider false or misleading information, which is benefits fraud. These practices could have serious consequences for you and/or your chiropractor.

Some benefit plans include deductibles and co-payments as part of their design. Your chiropractor does not have the ability to waive these fees that the insurance company charges and builds into its reimbursement process. For example, if your chiropractor submits a bill for a visit that cost $100.00 and there is a five per cent co-payment, the insurer will automatically deduct five dollars and the amount you receive in reimbursement will be $95.00.

A: No. Extended health care insurance is intended to cover the cost of medically necessary services or products. Each receipt submitted to your insurance provider must correspond to specific service(s) or product(s) that your plan covers and that you have already received and paid for. Submitting false or misleading information to your insurance provider is benefits fraud. This could have serious consequences for you and/or your chiropractor.

If your insurance coverage is ending and you need an orthotic but the cost is a financial hardship for you, we suggest you contact your insurance provider. Ask them if they can make an exception in your circumstances to allow you to submit a claim after the date when your coverage will change or end.

Alternatively, some chiropractors may offer reduced fees on compassionate grounds, on a case-by-case basis. Speak to your chiropractor for further information.

A: No. Under the Insurance Act, 1990, you must by law use your extended health care insurance before accessing your motor vehicle accident (MVA) insurance.

A: Some chiropractors may offer reduced fees on compassionate grounds, on a case-by-case basis. Speak to your chiropractor for further information.

Return to Is Chiropractic Care Covered?

[1] Allen, H., Wright, M., Craigh, T., Mardekian, J., Cheung, R., Sanchez, R., Bunn, W. and Rogers, W. (2014) Tracking low back problems in a major self-insured workforce: toward improvement in the patient’s journey. Journal of Occupational and Environmental Medicine, 56(6), 604-620.
[2] Tsertsvadze, A., Clar, C., Court, R., Clarke, A., Mistry, H. & Sutcliffe, P. (2014). Cost-effectiveness of manual therapy for the management of musculoskeletal conditions: A systematic review and narrative synthesis of evidence from randomized controlled trials. Journal of Manipulative and Physiological Therapeutics, 37(6), 343-362.
[3] Allen et al. (2014) Tracking low back problems in a major self-insured workforce