Supporting Patients to Understand their Extended Health Care Coverage

It is imperative that clear, consistent, and transparent communication take place between you, your patient, and your patient’s extended health care (EHC) insurance provider. This will help you avoid any misunderstandings, delays or denials resulting in unforeseen out-of-pocket payments for your patients.

Your patients should have a clear understanding of what they are covered for, as well as any conditions (e.g. prescriptions, pre-approvals), co-payments or deductibles that the terms of their plan may be subjected to, before they begin treatment.

Educating Patients

Patients should obtain details about their coverage directly from their insurer. Insurance providers typically make information available to employees (plan members) through online portals, mobile applications, print or digital employee benefits handbooks and through their customer service departments or online chat features.

You may also wish to inform your patients that insurance contracts often stipulate that coverage is subject to change. Insurance companies may re-evaluate their Reasonable and Customary fees or introduce new requirements for information or documentation to Adjudicate and pay a claim. For example, an EHC insurer may introduce a requirement for your patient to submit an invoice from the lab which made the custom orthotic.

Where necessary, you and your administrative staff can assist patients in understanding and keeping up to date with the details of their coverage. To help with this, we developed a Patients’ extended health care coverage checklist for you and your staff to support your patients. You can print or download The Patient’s Guide to Extended Health Care Coverage, to provide the checklist directly to your patients.

Sometimes EHC insurers may be confused about whether chiropractors are licensed to practise acupuncture or not. To facilitate communication with your patients and insurers on this subject, you can use this acupuncture and chiropractic care letter template that we developed.

Submitting Predetermination Requests

For privacy reasons, insurers will not provide the details of Plan member coverage to you. However, some insurers may enable predetermination requests to be submitted through third-party benefits management services. That means you can submit the pricing details of a specific treatment or product and receive information about whether it will be covered by the plan. You will also receive information about any conditions, co-payments or deductibles that may apply. This enables you to obtain answers to specific queries about coverage, without compromising your patient’s privacy.

Patients’ Extended Health Care Coverage Checklist

We recommend that patients understand the following details of their coverage before commencing treatment with you.

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. Is there a Health Spending Account (HSA) or Personal Spending Account (PSA) included in my policy? If so, how much is available?
3. What are the reasonable and customary fees, or the maximum amount that I can claim per visit?
4. Will my claim be subjected to any co-payments or deductibles? If so, how much and how often are they applied? (Note: An insurer usually charges co-payments on a per-product or service basis at each visit. However, an insurer generally charges a Deductible 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 interval?
6. How much of my coverage have I used so far? How much remains?
7. Are my spouse or 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

9. Does my benefits plan cover the product or device [make, model]?
10. 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 should be aware of?
11. What are the terms and conditions of coverage that I should be aware of?
12. Do I need Pre-approval?
13. Is a prescription required? Will my prescription expire after a certain time?
14. Under my EHC plan, which health care providers can prescribe the product or device?
15. Under my EHC plan, which health care providers can dispense the product or device?
16. Do I need to submit any other forms, paperwork or documentation to be covered?
17. For orthotics: What casting technique is required?

Acupuncture and Chiropractic Care Letter Template  

[Insert Date]
[Insert Name and Address of Recipient]

Letter of Information Re: Acupuncture and the Chiropractic Scope of Practice

To Whom it May Concern:

This letter is to confirm that in Ontario, acupuncture is considered a treatment that is included in the scope of practice of several health professions, including chiropractic care. This means that chiropractors can use acupuncture to treat their patients if they do so in a manner that is within their scope of practice. However, chiropractors are prohibited from calling themselves “acupuncturists” unless they are dual registrants of the College of Chiropractors of Ontario (CCO) and the College of Traditional Chinese Medicine Practitioners and Acupuncturists of Ontario (CTCMPAO).

Members of the CCO are authorized under Regulation 107/96 of the Regulated Health Professions Act, 1991 (RHPA) to perform acupuncture. Section 8 (2) of the Regulation provides an exception to the RHPA which allows specified health professions, including chiropractic care, to perform “acupuncture, a procedure performed on tissue below the dermis, in accordance with the Standard of Practice and within the scope of practice of the health profession.”

For more information on acupuncture and the chiropractic scope of practice, as well as the training and education requirements for chiropractors in the use of acupuncture as a treatment modality, please consult CCO Standard of Practice S0-17: Acupuncture.