A common question at Newleaf Total Wellness Centre is, “Is this covered?”. When you have coverage for a service, your health plan will contribute payment towards some or all of the costs. Do you ever wonder why your clinic staff can’t tell you what your health insurance coverage is for chiropractic, physiotherapy, massage therapy or other services? You’re not alone. In this post, we will explore why that is the case and look at some steps you can take to understand your exact healthcare coverage better.
Why your clinic can’t tell you about your healthcare plan coverage.
It’s important to understand that your personal health information, including service utilization, is highly confidential. This information is available only to you and your benefit provider. Clinics and healthcare providers can only access payment information without any other details. When the clinic submits your treatment for coverage to your insurance provider, the system will tell them only if you have coverage – yes or no. If you have coverage, it will let the clinic know how much your plan will cover for the treatment submitted. It will not tell the clinic your total amount of coverage, how much your deductible or patient portion is, or any other details about your plan.
But my dentist can check to see if a treatment is covered.
While dentists may need to contact your insurance provider for pre-approval for crowns or other major dental work, they do not do so for routine treatments like cleanings and fillings. Similarly, your physiotherapist, chiropractor, RMT or acupuncturist cannot get pre-approval before you arrive for routine appointments such as a one-hour massage or fifteen-minute chiropractor appointment.
Your dentist cannot tell you how much your plan will cover or how much you have used to date. Like your clinic, they only receive information on whether the treatment is covered and how much your plan will contribute to that treatment.
The law.
Most believe that our medical and health information should remain private and protected. Under the PIPA (Personal Information Protection Act) and HIPAA (Health Insurance Portability and Accountability Act of 1996), BC Provincial and Canadian Federal laws give you rights over your personal and health information.
These laws also establish rules on who can see your health information. The rules apply to health plan administrators, insurance companies, employers, and government programs providing healthcare. Additionally, these laws cover most healthcare providers who process electronic transactions, such as billing your health insurance, including doctors, clinics, and hospitals.
How do I know what my coverage is?
Many individuals have healthcare coverage through their employer or spouse’s employer. The coverage and payments provided by your health plan depend on the details of the plan chosen by your company. It’s important to understand that every plan, even those offered by the same insurance company, provides different coverage for paramedical services, tests, and prescriptions. This variation is because there are many kinds of plans to choose from, and companies consider cost when selecting the most suitable option for their employees. Paramedical expenses refer to medical services or products received from licensed healthcare professionals who are not medical doctors or nurses. Examples of paramedical practitioners include acupuncturists, chiropractors, massage therapists, physiotherapists, podiatrists, and more.
Where Can I Find the Information?
Your paramedical coverage information can be found under your healthcare plan’s ‘Paramedical Services’ list. Please be aware that certain limits may apply to your coverage, such as a maximum number of visits or a maximum dollar amount covered per treatment or service. To review the limits specific to your coverage, refer to the ‘Limits’ section in your coverage details.
It is crucial to familiarize yourself with the coverage provided by your benefits plan and the out-of-pocket expenses for which you are responsible. Knowing what your plan covers will help you to avoid unexpected costs and disappointment. We recommend requesting an updated employee benefits booklet from your company to obtain information on maximum coverages and the disciplines covered.
For detailed information about your coverage, including the amount used and remaining, visit your benefit provider’s website. You must set up a personal profile with a username and password to securely access this information through their online portal or mobile app.
How Do Insurance Companies Decide How Much to Cover?
Insurance companies establish reasonable and customary (R&C) limits, which represent the payment range for specific health-related services or medical procedures. It’s important to note that these limits are often based on outdated average cost reports and may not accurately reflect current costs. Consequently, you may have to pay more for a service than your benefits cover.
Consider this example: Suppose you book a massage costing $130, but your insurance company’s R&C amount for this service is $100. Assuming your workplace plan covers 80% of massage therapy treatments, you would be eligible for a reimbursement of 80% of the R&C amount, equalling $80. You would have to pay the clinic $50.
More about other types of healthcare insurance coverage.
MSP Coverage
Residents of British Columbia are covered by the Provincial Medical Services Plan (MSP). MSP contributes $23 per visit for acupuncture, chiropractic, massage therapy, naturopathy, non-surgical podiatry, and physical therapy for people on income assistance, disability assistance, and hardship assistance. There is a combined limit of up to 10 visits per calendar year. However, it is crucial to mention that the government does not cover any charges related to extra billing, and this coverage is only available to some low-income recipients. If you believe you should qualify for MSP’s $23 contribution towards your patient fees, ask your clinic to check your eligibility online. Please note that the only information your clinic will receive is whether you are eligible.
ICBC Coverage
Suppose you have been involved in a car accident. In that case, you are eligible for a specific number of treatments that can last up to 12 weeks after the date of the accident. ICBC covers 12 Acupuncture appointments, 25 Chiropractic appointments, 12 Registered Clinical Counseling appointments, 12 Registered Massage Therapy appointments, 25 Physiotherapy appointments and 12 Kinesiology or Athletic Therapy appointments.
If you choose a clinic that directly bills ICBC, the clinic should be able to inform you of how many treatments you have left. However, it is always your responsibility to know how many treatments ICBC has approved for you and how many are left. You are always responsible for any treatments you receive that insurance does not cover.
ICBC has approved service coverage up to a certain fee per treatment; the patient must pay the remaining user fee.
 WorkSafe BC Coverage
If you get injured at work, it’s important to know the available options for coverage and support through WorkSafe BC. The crucial first step is notifying your employer and WorkSafe BC after the incident.
Physiotherapy
For physiotherapy, we advise scheduling an appointment with one of the approved clinics within the WorkSafe BC provider network. Even before your claim is approved, WorkSafe BC will cover the cost of your initial appointment. However, if you choose a physiotherapist not contracted with WorkSafe BC, you must pay for the visit and then get reimbursement from WSBC. Therefore, we recommend not to book subsequent appointments until your claim is approved unless you are willing to pay for them.
Registered Massage Therapy
Before getting treatment from a Registered Massage Therapist (RMT), you must obtain a referral from your doctor. Once your WorkSafe BC claim is accepted, you are entitled to up to six treatments within the first eight weeks of your injury. When choosing massage therapy, you should pick a provider who will directly bill WorkSafe BC and submit reports. To find an RMT, please visit the Registered Massage Therapists Association of BC website and use the WorkSafe BC filter. However, if you decide on a provider who does not bill WSBC directly, you must pay for your visit and then ask for reimbursement. Please note that WSBC will reimburse you at predetermined rates; any remaining balance will be your responsibility.
Referrals
WorkSafe BC does not require referrals for chiropractic, acupuncture, or naturopath treatments, and you may be entitled to receive up to eight weeks of treatments once WorkSafe BC has approved your claim. If you choose a provider who does not bill directly to WorkSafe BC, you must pay for the visit and then seek reimbursement. Again, remember that WSBC will reimburse you at established rates, and any difference will be your responsibility.
Your case manager must approve all dental work before you can receive it unless it is an emergency. WorkSafe BC covers emergency room visits, short- and long-term stays, day surgery, dressing changes, casting, and diagnostic imaging.
If you choose a clinic that directly bills WorkSafe BC, the clinic should be able to inform you of how many treatments you have left. However, it is always your responsibility to know how many treatments WorkSafe has approved for you and how many are left, as you are always responsible for any treatments you receive that insurance does not cover.
Conclusion
Understanding all associated fees and insurance coverage before attending paramedical services is essential. For those with limited financial means, MSP may contribute a small amount towards your treatment. Those who have had a motor vehicle accident may receive coverage through ICBC, and WorkSafeBC may provide coverage following a workplace accident.
The long and short of it is that the amount of insurance coverage you are entitled to depends on several variables. You must know your entitlements because privacy regulations restrict clinics from accessing most of this information.
We hope this blog post has explained why your clinic may be unable to inform you about what your insurance will cover and how financing paramedical services works.
Please note that this information is intended to provide educational insights and should not replace any specific guidance or advice provided by a healthcare professional or plan administrator.
Written by: DeVera Nybo, MBA CEO/Owner Newleaf Total Wellness Centre