The Public Programs Underneath Your Plan
You cannot advise well on private coverage without knowing the public floor underneath it — and that floor is currently moving.
The programs
OHIP and the provincial floor
Provincial health insurance covers physician and hospital care. It does not cover outpatient prescription drugs for most working-age adults, dental, vision, or paramedical services — which is precisely the space private group plans fill.
Worth stating plainly to employers who assume Canada has universal healthcare in the fullest sense. The benefits plan exists because the public plan deliberately stops where it does.
Ontario Drug Benefit
ODBPublic drug coverage for Ontarians 65 and over and for certain other groups, including recipients of social assistance and home care.
A plan’s drug costs typically fall as members reach 65, because ODB becomes the first payer. Relevant when interpreting a plan with an ageing workforce.
Trillium Drug Program
Assistance for Ontario households whose prescription drug costs are high relative to household income, after an income-based deductible.
A route worth knowing for a member facing catastrophic drug costs, even where the private plan responds. It exists for exactly the situations people assume have no answer.
Canadian Dental Care Plan
CDCPA federal dental program for eligible residents without access to employer or private dental coverage. Access to an employer dental plan generally disqualifies a person from it.
This changes a real conversation. An employer considering dropping dental should understand it may push staff toward a public program with its own eligibility tests rather than simply removing a benefit. Verify current rules before relying on this — the program is still being phased in.
National pharmacare
Federal legislation establishing first-phase public drug coverage in defined therapeutic areas, implemented through agreements with individual provinces.
Coverage and timing vary by province and are changing. Treat it as something to check the current state of before advising, not something to assert from memory.
EI sickness benefits
Federal income replacement during illness for eligible workers, for a defined number of weeks at a percentage of insurable earnings up to a maximum.
This is what usually bridges to LTD where there is no short-term disability plan. Knowing the current duration and maximum lets an employer see exactly what their people would live on.
CPP disability
CPP-DA federal benefit for those with a severe and prolonged disability preventing substantially gainful work. Approval is difficult and the standard is stricter than most LTD contracts.
LTD insurers routinely require claimants to apply, because an award offsets their liability. Members experience that as being pushed toward a benefit they will probably be denied — explaining why it is required defuses a common and genuine grievance.
Workplace Safety and Insurance Board
WSIBOntario coverage for work-related injury and illness, funded by employer premiums and entirely separate from the group plan.
Group plans exclude what WSIB covers. Disputes about whether an injury was work-related are therefore disputes about which system pays, and can leave a claimant temporarily with neither.