How do the two benefits plans calculate how much is paid back to members?
According to the Canadian Life and Health Insurance Association (CLHIA):
The plan that pays first will calculate payments as though another plan does not exist. This means you are paid back only for the amount that is reasonable and customary minus any co-insurance or deductible as per your plan.
The plan that pays second calculates payments, based on the lowest of:
- The amount that it would have paid if it had paid first, OR
- 100% of the cost minus the amount paid by the first plan
The combined payment from all plans cannot exceed 100% of the eligible medical or dental expenses. In some cases, the combined payment from all plans may be less than what you have paid out of your pocket.
Using the above example, Sasha got $40 back for the massage fee ($80) from his plan. When his spouse submitted the unpaid amount to their plan, the other insurance company calculations were as follows:
- The amount that it would have paid if it had paid first ($64), OR
- 100% of the cost minus the amount paid by the first plan ($40)
Therefore, Sasha got $40 back from his spouse’s plan—getting back 100% of his massage fee.
How do reasonable and customary limitations impact co-ordination of benefits?
Before you get any money back, deductibles, maximums or reasonable and customary apply as per the terms and conditions in each plan (refer to your benefits booklet).
This means you are paid back only for the amount that is reasonable and customary minus any coinsurance\reimbursement or deductible as per your plan.
Once the first insurance company pays the reasonable and customary amount, there may still be an unpaid amount if the service provider was charging more than what is considered reasonable and customary by the first payor. Therefore, depending on your plan coverage, you or your spouse may still end up having to pay a portion of the expense out-of-pocket even if you are covered under more than one benefits plan.
My son is 18-years-old and works full time. His job also give him benefits. Is he covered under my plan?
No, your son would not be covered under your plan and co-ordination of benefits does not apply in this situation. For your son to be covered under your plan, he must meet the following criteria:
- under age 21, or under age 25 if a full-time student
- not employed on a full-time basis
- not eligible for coverage as a member under this or any other group benefits plan
I have remarried and have joint custody of my two kids. How does co-ordination of benefits work between the different health plans (mine, my ex-spouse and my new spouse)?
For this kind of situation, you can call OTIP Benefits Services. We can help you understand how co-ordination of benefits works between all these different plans. We want to ensure you get the best coverage for your family and minimize your out-of-pocket expenses.
When do I need to contact OTIP Benefits Services about co-ordination of benefits?
You can call us if the one of the following situations apply to you:
- When parents are divorced or separated, the parent with full custody would send in the claim first to their insurance company. When there is joint custody, standard co-ordination of benefits applies (refer to the above Basic guidelines for submitting claims between two benefits plans).
- When a student is covered under a student health and dental plan. Student health and/or dental plans will pay the claim first.
Does my province’s health plan (e.g. OHIP) cover some of my expenses?
Your province’s health plan may cover some medical and health expenses.
Before you send us your claim:
- Ask your doctor or health professional if your province’s health plan covers part of the cost.
- If your province’s health plan declines your claim, send us a statement from them that explains their decision. Working with the insurer (Manulife), we will review and process your claim as per the terms and conditions of your benefits plan.
If I have benefits with my Employee Life and Health Trust Benefits Plan, should my spouse keep their benefits plan?
If you have access to more than one family benefits plans, it is a great way to maximize benefits. If you are thinking that you can save money by paying for only one benefits plan, consider how co-ordination of benefits works and what medical expenses you have before signing a waiver and giving up a second plan.
Consider having two benefits plans if the following situations apply to you:
- Married couples or domestic partners who each have access to a benefits plan through their employer
- Children with parents who each have access to a benefits plan and may choose to include the children on each plan
- Adult children (ages 18 – 25) who have coverage through their school and through their parents
If you are covered under one benefits plan only, then co-ordination of benefits does not apply to you.
Do I get double or more benefits if I am covered under more than one plan?
No. The combined payment from all plans cannot exceed 100% of the eligible expense. Co-ordination of benefits with another benefits plan may help cover some of your health and dental costs that are not completely covered under your own plan.
Who is the ELHT, OTIP and the insurer?
ELHT Board of Trustees
Managing and governing the ELHT benefits plan
The trustees manage the ELHT benefits plan in the best interests of the members, and makes a range of plan design, funding, administrative and investment decisions on their behalf.
Administrating the ELHT benefits plan
OTIP can help you with questions about your enrolment, the benefits you and your family are covered for (eligibility), the cost associated with these benefits, and the claims for health and dental care.
Issuing insurance policies and pays the claims