If you (or your spouse) have access to group benefits through your employer, you may have some coverage for the services of a registered mental health professional.  There are many different types of benefit plans, and each one has its own set of unique rules and claim guidelines, so it is very important to verify your own coverage.

 

Check Your Benefit Booklet

 

The Benefit booklet is an important document with all the unique details and information you need to know about your plan.

 

Your benefit booklet will outline what services are eligible and at what amount.  It will also provide instructions for submitting claims.  Furthermore, it will outline if your partner and/or dependent children are eligible for benefits.  If you do not have a benefit booklet, ask your employer how to access one.  If you have questions or are unsure about the details provided in the booklet, contact your benefits provider directly (contact details are found in the booklet).  If your employer has a Human Resources Department, they can often assist with benefit inquiries.  

 

Group Benefits 101

 

*Outlined below is some general information about typical group benefit plans in Ontario.  It is provided as information only and may not apply in all cases: Always verify what coverage you have with your benefit provider. 

 

Extended Health Plans

 

Extended Health plans may reimburse up to the total cost for a visit / session with a registered mental health practitioner.  Typically, you would pay for your session directly to the therapist and then submit a claim to your benefits provider for reimbursement.  Several provisions will apply:

• The plan will identify which types of practitioners are eligible (e.g. registered social workers, psychotherapist etc.).  Not all plans cover all types of practitioners.  

• Practitioners that are covered must be registered / licensed with their regulatory /governing body or claims would be denied by the benefits provider.  All the therapists on the Althea Therapy platform are required to be registered / licensed.

• The plan will include rules and timeframes for submitting claims.  A common rule is, no later than the end of the year in which the claim was incurred.  

• The plan will identify any maximums that apply.  It is common to see a maximum dollar that is eligible each calendar year for each covered person (e.g. $1,000 per calendar year).

• The plan will identify the reimbursement level.  It varies by plan but can be as much as 100%.  Other plans have a per visit maximum that applies (e.g. $60 /visit up to 12 visits /year.)   

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Reasonable & Customary Limits

 

Be aware that most, if not all plans, will apply what’s known as Reasonable & Customary (R&C) limits to all covered services. 

 

R&C generally refers to the fees that are normally charged by the type of practitioner in the regional area where the service is provided.   It helps to support more consistency in pricing.  Note that R&C limits can vary slightly by benefits provider. Practitioners on the Althea Therapy platform set their own pricing.  

 

Ultimately, R&C means that even if your plan reimburses 100%, if the therapist charges more than the R&C limit, your claim would only be reimbursed to the R&C and you would find yourself out of pocket for the difference.

 

Spending Accounts

 

A Spending Account is a set amount of money your employer allocates to you to help pay for certain expenses.  It is a set amount of money, rather than a set amount of benefit (i.e. an extended health plan).  This means in most cases you get to choose what services to spend it on.    

 

Spending Accounts are administered by a benefits or specialty provider.  You pay for your expenses and submit eligible claims for reimbursement.  There are rules that dictate what is eligible, how long you must submit a claim and when any funds are forfeited if you haven’t used it all.  If you have access to a spending account, verify these and any other special rules or restrictions that may apply.  Details are usually found in the benefit booklet.  

 

There are two different types of Spending Accounts:  

 

Health Spending Accounts:  Health Spending Accounts are non-taxable and can be used for items or services that are considered a medical expense under the Income Tax Act.  (Note that some employers will stipulate which of these expenses are eligible.) 

Therapy sessions with a registered psychotherapist or social workers are examples of an eligible expense under the Income Tax Act. 

 

Personal Spending Accounts:  Personal spending accounts are taxable and can be used for a wide range of services that may or may not be a medical expense under the Income Tax Act.  

 

Althea Therapy Products & Services

 

Subject to the specific contractual provisions of any given group policy, the following is general information on the handling of Althea Therapy products and services: 

 

Therapy:  Counselling sessions may be eligible under extended health plans, as well as both types of spending accounts.

 

Reclaim Program:  The learning portion of the Reclaim Program is not eligible under extended health care plans or health spending accounts.  

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However, the Reclaim program also includes 2 live group sessions, at a minimum, conducted by a registered psychotherapist or social worker.  Attendance at these sessions may be considered an eligible expense under an extended health plan, as well as a health spending account.  Please check with your benefit provider.

 

The Reclaim Program would typically be considered an eligible expense under a Personal Spending Account. Be sure to check however as some employers do limit what is eligible under these accounts.  

 

Membership Fees:  Membership fees are not eligible under extended health care plans or health spending accounts.  

 

Membership Fees would typically be considered an eligible expense under a Personal Spending Account.  Be sure to check however as some employers do limit what is eligible under these accounts.  
 

* All the above is provided as general information only.  It does not constitute specific advice, nor does it confirm or infer any coverage under any group policy.