Back to all terms

Eligible Expenses

An eligible expense is any medical or dental service, product, or treatment that qualifies for reimbursement under the terms of your insurance plan. To be eligible, the service must meet several criteria: it must be medically necessary, performed by a licensed or approved provider, and fall within the plan’s specific limits and exclusions.

How It Works

Insurers define eligibility so that benefits are paid only for valid, health-related needs rather than elective or cosmetic procedures, which is why services such as cosmetic surgery or over-the-counter supplements are usually not eligible unless they are specifically listed in your policy. Once you submit proof that you have incurred an eligible expense, the plan administrator reimburses you, with the amount subject to any eligible-expense maximums, the annual deductible, and any co-payment. Under a private health services plan, an expense is eligible for tax-free reimbursement only if it qualifies under the Income Tax Act (Canada) for the medical expense tax credit and is not, or is only partially, covered by another public or private health plan. The Canada Revenue Agency treats a plan as a private health services plan only where all or substantially all of the premiums relate to expenses eligible for that credit, and those eligible expenses cover a wide range of products, procedures, and services, including medical supplies, dental care, and travel.

Example:

Under a typical Canadian extended health plan, a routine dental cleaning performed by a licensed hygienist is an eligible expense and qualifies for reimbursement, while teeth whitening done purely for cosmetic reasons is not. Even a medically necessary service can be ineligible if it is performed by a provider the insurer does not recognize as licensed or approved.

What to Watch For:

Eligibility depends on more than the service itself. A practitioner-based service such as massage therapy, naturopathy, or acupuncture only counts as an eligible expense in provinces where those practitioners are authorized under the CRA's list of authorized medical practitioners, so where the care is delivered matters. For the medical expense tax credit, you can claim only the part of an eligible expense for which you have not been and will not be reimbursed. Always confirm that your provider is licensed and recognized by your insurer, since an otherwise valid, health-related service can still be denied when it falls outside the plan's specific limits and exclusions.

Related Terms

Coverage / Benefit

Coverage, sometimes referred to as a benefit, is the range of health or dental services, supplies, or treatments that your insurance plan agrees to pay for under its terms and conditions. Each benefit represents a category of care, such as prescription drugs, dental services, vision care, or paramedical treatments.

Healthcare Spending Account (HCSA)

A Healthcare Spending Account (HCSA) is a flexible, employer-funded benefit that reimburses employees for a wide range of eligible healthcare expenses not fully covered by their group insurance plan or a government health plan. It allows employees to use allocated funds toward medical, dental, and vision expenses based on their personal needs. The Canada Revenue Agency (CRA) regulates which expenses qualify under the Income Tax Act, and reimbursements from an HCSA are received tax-free.

Extended Health Care Insurance

Extended health care insurance (EHC) is supplemental coverage that helps pay for medical expenses not covered by your provincial or territorial health plan. It protects you from out-of-pocket costs associated with services such as prescription drugs, vision care, medical equipment, hospital upgrades, emergency travel medical care, and paramedical services like physiotherapy or chiropractic treatments.

Health Insurance

Health insurance is a type of coverage that helps pay for medical and healthcare expenses not fully covered by Canada’s public health system. It protects individuals and families from the high cost of prescription drugs, medical services, and treatments that fall outside provincial or territorial government health plans. Health insurance can be obtained through an employer’s group benefits plan or purchased individually from a private insurer.

Treatment

Treatment refers to any medical, dental, or therapeutic care provided by a licensed healthcare professional to diagnose, manage, or improve a health condition, injury, or disease. In the context of insurance, treatment includes all services, procedures, medications, and interventions that are deemed medically necessary to restore or maintain health. It can range from routine doctor visits and prescription drug use to surgery, rehabilitation, and specialized therapies.

Relevant Plans

Plans that relate to Eligible Expenses

Alberta Blue Cross - Blue Assured - Basic

Alberta Blue Cross - Blue Assured - Basic

Can apply at anytime, at any age.

Alberta Blue Cross - Blue Assured - Enhanced

Alberta Blue Cross - Blue Assured - Enhanced

Can apply at anytime, at any age.

Alberta Blue Cross - Blue Assured - Enhanced+

Alberta Blue Cross - Blue Assured - Enhanced+

Can apply at anytime, at any age.

Alberta Blue Cross - Blue Assured - Premium

Alberta Blue Cross - Blue Assured - Premium

Can apply at anytime, at any age.

Have questions about your insurance coverage?

Our licensed advisors can help you understand your options and find the right plan for your needs.

Contact Us