Provincial Coordination
Provincial coordination refers to the process of aligning private insurance benefits with the coverage provided by your provincial or territorial government health plan. It ensures that the public plan pays for all eligible expenses first, and your private insurance covers only the remaining costs that are not paid by the government. This coordination helps prevent duplicate payments while maximizing your overall coverage.
How It Works
In Canada, each province and territory has its own publicly funded health insurance plan, and the provinces and territories receive a federal cash contribution to administer their plan through the Canada Health Transfer. Under the Canada Health Act, these public plans must cover medically necessary hospital, physician, and certain surgical-dental services, which are called insured health services. Provinces and territories also provide a range of services that fall outside the Canada Health Act's definition of insured services, such as dental and vision care, and the scope of coverage and eligibility criteria vary from one province or territory to another. When a person has more than one health plan, coordination of benefits determines which plan pays first and how much each plan contributes, which avoids duplicate payments and overpayment by insurers. Under CLHIA Guideline G4, the combined payment from all group plans for a particular item cannot exceed 100 percent of the eligible medical or dental expense.
Example:
Consider a Canadian who has a routine dental cleaning and is covered by both a provincial dental program and another plan. The claim is coordinated so the primary payer pays its eligible portion first, and the secondary payer covers the remaining balance up to its own limits. The combined payment cannot exceed the full eligible cost of the cleaning. In practice, the claim is submitted to the primary payer first, which generates an Explanation of Benefits showing the eligible amount, after which the provider submits the remaining balance to the secondary payer program within a set deadline.
What to Watch For:
The primary responsibility of a covered individual in coordinating out-of-country or out-of-province or territory medical expenses is to disclose all sources of available coverage, so insurers and plan administrators can coordinate the claim. Keep in mind that some services subject to frequency limits are not cumulative across coordinating plans, so neither plan will provide coverage for services beyond its own respective frequency limits. Because the scope of coverage and eligibility criteria vary from one province or territory to another, it is worth checking how your plan coordinates benefits with your provincial health plan.
