Posted at 5 years ago in blog by M Lederman

In any given benefits plan, often the most used benefit is the allowance for Professional Services (also known as Paramedical coverage). This includes a range of services like physio, chiropractic, acupuncture and everyone’s favourite – massage. Below is an email from a real client, which serves as a great example of the most common question we receive:

Hi Matt,

I am going through the information package, and I had a question for clarification.

I see 80% coverage for various Professional Services.

I see it states “$300 per calendar year” for several professional services.

Is that $300 per service type? Am I covered for $300 for Massage Therapy AND $300 for service form a Podiatrist? Is it either or?

Does the $300 mean if I were to have a $375 bill for something, I would get 80% ($300) covered? or does that mean only $240 of that is covered (80% of $300)?

Per Calendar year; Does that mean the $300 coverage rolls into the next year’s pool on January 1st? or in September (Whenever our benefits started)?

Thanks!

This question is very thorough, as it addresses three factors of plan design in one:

• Co-insurance: The percentage of the bill the insurance plan pays.
• Maximum: When does the benefit run out? When does it renew?
• Mechanics: Do I pay 20% of the bill out of my own pocket? Does that contribute to the maximum?

Below is my actual response. Despite being somewhat case specific (this plan is administered by Manulife, and the services covered will vary depending on your plan) hopefully this clears up from a high level any confusion about how the process works:

Hi _____,

The $300 allowance is per practicioner, as in you have $300 for each of them. The practicioners covered are as follows:

Chiropractor, Osteopath, Podiatrist/Chiropodist, Massage Therapist, Naturopath, Speech Therapist, Physiotherapist, Psychologist, Acupuncturist

The co-insurance is 80% up to $300 meaning each individual bill you get, 80% can be direct billed to the plan using your card. The remaining 20% you will have to pay out of pocket. Think of it as a $300 allowance that Manulife is prepared to cover, as many visits as it takes to get to that number. However each time you pay 20% of the bill out of pocket.

Using your example above, if your bill was $375 with the physiotherapist for instance, $300 would be covered and you would pay $75, and your allowance for that practicioner would be exhausted for the year. However if your bill was only $150, you would pay $30 and $120 is billed to the plan, leaving your balance for physio at $180 for future visits. You can’t dip into the pot further to get 100% covered on any given bill unfortunately. Most places will be equipped to handle Manulife claims on the spot.

These services renew on a calendar year basis, so yes you have until January 1 with the current $300 for each. It does not carry forward any unused portion to the next year, but will “re-load” to $300 each again for 2018. This same logic applies to your prescriptions and dental work as well, albeit with different maximum amounts.

Have a great day,

Matt