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Group Health and Dental Insurance Specifics Every Employee Should Know

By: Benefits by Design | Tuesday August 16, 2022

Updated : Thursday September 15, 2022

There are a lot of little details within a health and dental plan. Understanding what they all mean can play a crucial role in making sure you don’t find yourself paying too much out-of-pocket for a medical expense. Whether it be due to your coverage not being effective, a maximum reached, or the type of service, we’ll give you the knowledge to use your benefits plan effectively.

Health and Dental Coverage Specifics

Within your extended health and dental coverage, there are many details to consider. We’ll explain each one, as well as the significance of understanding them.

How to Read and Understand Your Schedule of Benefits

Is There a Waiting Period? How Long is it?

A waiting period is the time that must be satisfied before an employee’s benefits begin. A common waiting period length is 3 or 6 months, but it is completely up to the employer to decide this when they are setting up the plan design. Different employee types can even have different waiting periods. It is important to keep in mind that the benefits waiting period is different than the probational period.

The beginning of the waiting period is usually the first day worked, but this is not always the case. For example, if only full-time employees are eligible for benefits, a part-time employee who becomes a full-time employee would begin their waiting period on the first day of full-time work.

What is the Difference Between Frequency Limits and Annual Maximums?

It is important to understand what the insurers are referring to when they indicate a maximum for a specific health and dental expense.

An annual maximum means they will reimburse you for up to the maximum amount for that particular service or medical item, within that calendar year. Most plans have a calendar year from January 1 to December 31, but sometimes they are set up to match a company’s fiscal year. So, even if you don’t use the coverage until November, the maximum will reset on January 1^st and you will have access to coverage again.

Frequency limits work differently. You’re eligible for coverage up to a maximum amount, but with a specific time-frame attached as well. For example, you might have coverage for hearing aids at a maximum of $700 every 5 years. In this case, the first time you purchase hearing aids becomes the basis for the frequency setting. If you bought your hearing aids on June 1^st, 2022, you would not be eligible to be reimbursed for another set until June 2^nd, 2027.

Why You Shouldn’t Max Out Your Benefits Plan

Do You Have a Per Practitioner Maximum?

Paramedical services include practitioners such as massage therapists, acupuncturists, chiropractors, nutritionists, and more! Almost all benefits plans will have a paramedical maximum.

Some health and dental plans are set up so that each type of paramedical practitioner has a separate maximum. However, other plans have a maximum for all paramedical practitioners combined. This means that if you use up to the maximum on massage, you would no longer have coverage for both massage and other paramedical services.

Is Vision Covered? Eye Exams Only?

When reading your summary of benefits, you will often see Vision Care or Eye Exams. For example, it might say: Vision Care – every 24 months for adults and dependent children. This means that you have access to eye-exams once every 24 months – this is your frequency limit. If there is a specific amount indicated, such as $250, this amount represents the coverage maximum for eyeglasses and/or contact lenses.

Is Travel Insurance Included? What are the Maximums?

Travel Insurance is often included under an employer sponsored health and dental plan. It is best to confirm this before you travel, and remember that even travelling within Canada but outside your province of residence means you should have emergency travel coverage.

Check the following specifications:

Maximum number of days per trip– how many consecutive days are you covered for when out of the country/your province of residence.

Emergency Services – what is the maximum amount the insurance company will pay for an out of country/province emergency. This is usually around $1-5million, but it is good to be aware of.

Referral Services– this represents the maximum amount that will be reimbursed for medical treatments/expenses that are performed out of country because the treatment was not available where the plan member resides. This usually requires pre-approval, and a referral from the plan members’ attending physician.

What is Travel Insurance and What Do I Need to Know Before Travelling?

Dental Coverage

Not all dental plans were created equal. The coverage is broken down into three main categories:

Basic – covers everything from scaling, cleaning, x-rays, check-ups and even fillings. Insurers usually reimburse basic services at 70-100%.

Major Restorative – covers services such as crowns, bridges and dentures. This coverage is commonly only reimbursed at 50%. Often, there will be a combined annual maximum for both Basic and Major Restorative services.

Orthodontics – covers expenses for braces. Orthodontic services often include a lifetime maximum, and sometimes only coverage for dependent children is offered.

How Dental Fee Guides Affect Group Insurance Plans

What Are the Costs of a Health and Dental Plan for an Employee?

So, you’ve got a new job and a great new benefits package. While it is employer sponsored, it doesn’t mean it is completely cost-free for an employee.

Coinsurance

This is the percentage of the cost that an insurer will reimburse you for. A common coinsurance amount is 80/20, meaning you would pay 20% and the other 80% would be covered by the health and dental plan.

Deductible

This is the amount that you would pay out-of-pocket before the benefits plan kicks in. The charge can be for any eligible medical expense. And even though it is not reimbursed, it is important to submit the expense under your plan so that the insurance company knows you have paid the deductible.

Cost-Sharing

Cost-sharing is used to describe the arrangement between the employer and employee in terms of who pays the health and dental premiums. Some employers pay 100%, but it is not uncommon to see a 50/50 cost sharing arrangement. These amounts are usually deducted through payroll, and therefore are barely noticeable. Check your pay-stub if you are unsure about what amounts you are paying.

The particulars of your employee benefits plan can significantly affect your decisions when it comes to purchasing medical supplies. Or when it comes to going to the chiropractor, or getting major restorative dental work. With a little diligence, you can utilize your plan correctly, and not be caught off guard by frequency limits or annual maximums. Remember to confirm the details of your benefits plan before you start using it.