SUPPLEMENTARY HEALTH INSURANCE
Deductibles, Coinsurance and Maximums
Supplementary plans typically do not pay 100 per cent of eligible expenses. You
may have to pay for a small amount of your expenses and those of any covered
dependents at the beginning of each plan year, called a deductible. Common
deductible amounts are $25 or $50 per covered person. Alternatively, you may
pay a family deductible, which might be the first $75 in eligible expenses incurred
by any two covered members of your family at the beginning of each year. Some
plans also include a per service deductible (e.g., $5 per drug prescription).
If your plan has a coinsurance feature, you will also be required to coinsure, or
pay, a percentage of your eligible expenses in excess of your deductible. The
coinsurance percentage is typically 10 per cent or 20 per cent of an eligible
expense, but may be higher for certain types of services (e.g., 50 per cent for
major restorative dental services or orthodontic treatments).
Many plans also place dollar limits, called maximums, on the amount of benefits
that will be paid for certain services, such as eyeglasses or orthodontic treatments,
in a specified period. Sometimes a maximum applies to the total benefits that will
be paid during a year or during the covered person's lifetime.
It is very important to know what deductibles, coinsurance percentages and
maximums apply to your eligible expenses. Check your plan literature carefully.
Predetermination of Benefits
For large expenses, such as major dental restorations, your plan may ask you to
obtain a predetermination or estimate of the benefits payable from the insurer before
you receive treatment. The predetermination of benefits will tell you how much the
plan will pay and how much of the expense of a specific course of treatment you will
be responsible for. It will allow you to budget for your share of the expenses, and to
see if you can cover more of the cost by coordinating your benefits with those of
your spouse/partner (see below).
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