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Looking at your paramedical services


Your plan provides you with coverage to ensure you get the best care for your well-being, including products and services that are medically necessary. This may include paramedical services. These are treatments offered by health-care professionals such as physiotherapists, chiropractors, massage therapists, podiatrists, psychologists, etc.

Let’s get started.

Review your benefits booklet to find out:

  • Which paramedical services are covered under your plan

  • If a doctor’s referral is required (e.g. massage therapist)

  • The maximum amount covered for each benefit year

  • Your benefit/policy year (e.g. September 1 – August 31, January 1 – December 31)

  • Any coinsurance or deductible that you pay towards the cost of the service or item

Ensure your provider is in good standing.

  • To protect and sustain your benefits coverage under your Employee Life and Health Trust (ELHT) Benefits Plan, the claims payor, sometimes finds it necessary to disallow certain service providers/suppliers from claims processing and reimbursement. This is referred to as being “delisted.”

It is important that you check the delisted providers list to ensure your new and current providers/suppliers are in good standing before you book your appointment. If the provider/supplier is on the delisted providers list, these claims will not be approved or eligible for reimbursement.

There are maximum allowable amounts (also called reasonable and customary limits, or R&Cs for short) that an insurer will reimburse on a service or item. This amount reflects the typical cost associated with this service or product in a specific geographical region. While physicians, dentists and hospital services adhere to a provincial fee guide, paramedical service providers can charge whatever they choose for their services and supplies.

 
For example:

You visit a registered and licensed physiotherapist who charges you $150 for the initial assessment. The reasonable and customary limit for this service in Ontario is $134. When you submit your claim, the claim payor will use their R&C limit to determine how much you will be reimbursed. In this case, you will be reimbursed $134 and pay $16 out-of-pocket.

 


Therefore, the insurers/claim payors have established R&C limits to ensure claims are not excessive and to reduce benefits fraud or abuse.

You can find Practitioner R&C by logging into your account and accessing My Claims.


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To see your maximum coverage in a benefits year, you can go into My Benefits under Coverage & Balances. You’ll see details on your Vision, Dental and Paramedical coverage, and for some benefits we even keep track of how much you’ve used, so you’ll be able to see your remaining coverage for this benefits cycle.

By getting estimates and treatments with providers who are in good standing and focused on getting you better, you can avoid surprises and disappointments, reduce your out-of-pocket expenses and ultimately, be a healthier you.

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