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Will you Integrate With Ontario Government's Dental Plan?

Posted by Gordon R. Hart

Apr 2nd, 2018

Will you Integrate With Ontario Government's Dental Plan?

Kathleen Wynne's pre-election budget had plenty of goodies for taxpayers as we approach a fall election. One of the more interesting developments was the announcement of a provincial dental program for all Ontario residents not covered by a workplace health insurance plan. The details of the plan were limited, but suggested that 80% of eligible dental expenses up to a maximum of $400 for a single person, $600 for a couple and $700 for a family of four with two children.

The question becomes, will plan Ontario sponsors adjust their plan to integrate with the government program? It would be expected that any government program would be second payer to private coverage (unlike OHIP+ which is first payer for eligible drugs taken by Ontario residents under the age of 25). Plan sponsors (employers) could implement deductibles on their plans to trigger out-of-pocket expenses that could qualify for the provincial dental plan. A deductible of $400 for a single person, $600 for a couple and $700 for a family of four with two children could be utilized to upload the risk to the provincial plan and provide coverage above the deductible threshold for treatment not reimbursed. Alternatively, plan sponsors could use health spending accounts versus insured plans. Most provincial programs do not integrate with health spending accounts since there is no "defined" coverage.

Before we get too far, I will admit that it is unlikely that the government programs will work as efficiently and effectively as workplace health plan. One only needs to consider the inefficiency of submitting claims under OHIP+ versus the prior experience with the workplace health plan.

The strategy of integrating with a government dental plan would be similar to plan sponsors (employers) installing limitations on prescription drugs to trigger access to the Trillium Drug program (Ontario's financial assistance program for families with out of pocket expenses above 3-4% of net family income). A recent study published in the Canadian Medical Association Journal reports that utilization of the Trillium program is on the rise. While the study did not determine whether private payer plan design has led to increased exposure to the program, anecdotal evidence would suggest integration approaches are part of the increase.

Plan sponsors must decide whether to complement or substitute for government programs. While traditionally Ontario plan sponsors have substituted (unlimited drug coverage, physiotherapy coverage etc.), there is a case to be made that complementing the programs allows for plans to increase the breadth of offerings into areas that the government programs do not address. For example, Employee Assistance Programs, Patent Assistance and Navigation Services, Second Opinion Services, Wellness Programming, and Pension plans are services and programs that can improve plan member physical, mental and financial health, but benefits budgets may not have the room for investment.

There will more to the story as the Ontario government determines the final details of the policy announcements, but the time is right for plan sponsors in Ontario to consider how they can better manage the benefit plan risks and coverage. Let's face it, taxpayer dollars are funding the programs, we all pay for them whether we use them or not.

Ask your benefits advisor about their strategy to integrate with government programs.

Will you Integrate With Ontario Government's Dental Plan?

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