Understanding Health and Dental Insurance in Canada: A Practical Guide

Whether you're starting your first job with health benefits, aging out of your parents' plan, or shopping for individual coverage, navigating health and dental insurance in Canada can feel overwhelming. This guide will help you understand how your benefits work—whether they’re provided through your employer or purchased privately—and explain the key terms and concepts you’ll come across.

Government Health Insurance Plans (GHIP) vs. Extended Health Coverage

Every Canadian is covered under their province or territory’s Government Health Insurance Plan (GHIP), which includes essential medical services like doctor visits, hospital care, and surgeries. However, GHIP doesn’t cover everything. That’s where extended health insurance—either through an employer-sponsored plan or a personal plan—comes in.

Extended health insurance helps cover costs for:

• Prescription medications
• Dental care
• Vision care
• Paramedical services (e.g., massage, chiropractic, physiotherapy)
• Medical equipment
• Emergency travel medical insurance

For example, if you sprain your ankle, GHIP will cover your visit to the ER. But if you need follow-up physiotherapy or a custom ankle brace, extended health insurance steps in to cover some or all of those additional costs.

Special Authorization

Some medications require additional approval before your plan will cover them. This process, called special authorization, ensures certain higher-cost or specialized drugs are prescribed appropriately.

Your doctor submits a form explaining why the medication is necessary—perhaps because other treatments didn’t work or aren’t suitable for you. Once approved, the medication is covered under your plan. It might seem like an extra step, but this process helps balance access and cost-effectiveness.

Step Therapy

Step therapy is another method insurers use to manage costs while ensuring effective care. It means starting with the most cost-effective treatments first—usually generic or lower-priced medications—and moving to more expensive alternatives only if needed.

For instance, if you're being treated for anxiety, your plan might ask you to try a generic medication first. If it’s not effective or causes side effects, your doctor can request approval for a different, more expensive drug.

Explanation of Benefits (EOB)

After you submit a claim, you’ll receive an Explanation of Benefits (EOB). This document shows:

• What was covered
• How much your plan paid
• How much (if any) you owe

Think of it as a detailed receipt—it helps you track claims, monitor your usage, and ensure everything was processed correctly. Always review your EOBs to catch errors and stay informed.

Medical Underwriting

When applying for personal insurance, you may be asked to complete medical underwriting—a review of your health history, medications, and existing conditions. This helps insurers assess risk and determine your eligibility or pricing.

Example: if you disclose asthma, the insurer might request more details about how it's managed and whether it requires ongoing medication. Based on this, they may include an exclusion for asthma or adjust your premiums.

Understanding this process lets you provide accurate information and select the most appropriate plan.

Paramedical Practitioners

Extended health plans often cover services from paramedical practitioners, professionals who offer care outside of traditional physician services. These may include:

• Physiotherapists
• Chiropractors
• Massage therapists
• Dietitians
• Psychologists
• Acupuncturists
• Occupational therapists
• Speech therapists
• Social workers
• Naturopaths
• Osteopaths

Coverage limits and eligible services vary by plan, so check the specifics to know what’s included.

Waiting Periods

Some plans include waiting periods—delays before certain benefits become available. For example, basic dental coverage might be available right away, while major dental procedures (like crowns or bridges) might only be covered after 12–24 months.

However, if you're moving from an employer-sponsored plan to a personal plan within a specific window, some insurers may waive waiting periods entirely. Understanding your plan’s timeline can help you avoid surprises and delays.

Stability Clauses

Stability clauses apply to pre-existing conditions, especially in travel insurance. They require your condition to be stable—meaning no changes in symptoms, medications, or treatment—for a specified period (typically 90 to 180 days) before your coverage is valid.

Even minor changes, like adjusting a medication dosage, could reset the clock. Always check the stability clause before booking travel to ensure you’re properly covered.

Employer Plans vs. Personal Plans

Employer-sponsored (group) benefits are provided through your job. Your employer usually covers part of the cost, making them more affordable. They offer set coverage levels, which may or may not suit your individual needs.

Personal health insurance plans, on the other hand, are paid entirely by you and can be tailored to your specific health needs—though they generally cost more.

Features you might find in an employer plan:

• Coordination of Benefits (COB): If you’re covered under more than one plan (e.g., through your partner), COB determines which plan pays first. The second plan may reimburse remaining eligible costs.
• Health Spending Account (HSA): A non-taxable account your employer funds. You can use it to pay for eligible out-of-pocket health and dental expenses.
• Wellness Spending Account (WSA): A taxable benefit you can use for wellness-related expenses like gym memberships, fitness gear, or continuing education. This is alternatively known as a Lifestyle Spending Account (LSA).

Take Charge of Your Benefits

Health insurance doesn’t have to be complicated. Understanding how your plan works—from what's covered to how to submit claims—empowers you to make smart, informed decisions about your care.

Whether you’re insured through work or buying coverage on your own, knowing the basics ensures you get the most out of your plan—and the best care possible.

Visit Aeva.ca to explore plans for yourself and your family.