Written by: Steffen deGraaf

Group Benefits Consultant, AEC Benefits

When it comes to health and dental benefits in Ontario, there are plenty of questions surrounding what’s covered, what’s not, and how to maximize available coverage. While employee benefits plans provide essential support for medical expenses, gaps in coverage can leave employees facing unexpected out-of-pocket costs.

This guide will break down what’s included in standard health and dental plans, common misconceptions, and how Health Spending Accounts (HSAs) can bridge coverage gaps.

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Table of Contents

1. What Are Health & Dental Benefits in Ontario?
2. Breakdown of Covered Services
3. Common Misconceptions About Coverage
4. How to Fill the Gaps with Health Spending Accounts (HSAs)
5. Frequently Asked Questions
6. Conclusion

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1. What Are Health & Dental Benefits in Ontario?

Health and dental benefits in Ontario refer to employer-sponsored insurance plans that provide coverage for medical expenses not covered by the Ontario Health Insurance Plan (OHIP). These plans are designed to help employees and their families manage everyday healthcare costs, ranging from prescription medications to routine dental exams.

While OHIP provides coverage for basic hospital and physician services, most dental, vision, and prescription drug costs fall outside of provincial healthcare. This makes group benefits a critical part of employee compensation, helping reduce the financial burden of healthcare expenses.

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2. Breakdown of Covered Services

A. Health Benefits Coverage

Most group health insurance plans cover essential medical services, including:

✔ Prescription Drug Coverage – Typically covers a portion of medication costs, with some plans requiring co-pays or deductibles.

✔ Paramedical Services – Includes physiotherapy, chiropractic care, massage therapy, acupuncture, and more.

✔ Vision Care – Coverage for eye exams, prescription glasses, and contact lenses.

✔ Mental Health Support – Access to psychologists, social workers, or Employee Assistance Programs (EAPs).

✔ Medical Equipment & Supplies – Coverage for prosthetics, hearing aids, orthotics, and mobility aids.

✔ Emergency Travel Medical Insurance – Helps cover unexpected medical costs when traveling outside Canada.

B. Dental Benefits Coverage

Dental benefits in Ontario vary by plan but generally include:

✔ Preventive Dental Care – Routine cleanings, X-rays, fluoride treatments, and check-ups. ✔ Basic Dental Work – Fillings, extractions, and root canals. ✔ Major Dental Services – Crowns, bridges, dentures, and orthodontics (coverage varies by plan). ✔ Periodontal Services – Treatments for gum disease and deep cleanings.

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3. Common Misconceptions About Coverage

Myth #1: “All Prescription Drugs Are Covered”

Many people assume that all medications are covered by their group benefits plan. However, coverage depends on the insurance provider’s drug formulary (a list of approved medications). High-cost specialty drugs or weight-loss medications (like Ozempic) may require prior authorization or might not be covered at all.

Myth #2: “Dental Work is Fully Covered”

Most dental plans cover a percentage of the costs for procedures (e.g., 80% for basic care, 50% for major treatments). Employees are often responsible for co-pays and deductibles.

Myth #3: “I Can Use My Benefits for Any Health Service”

Certain paramedical services (e.g., massage therapy, acupuncture) may have annual limits or require a doctor’s referral for reimbursement.

Myth #4: “My Benefits Stay the Same Each Year”

Employers regularly review and adjust benefits plans based on costs and employee needs. Coverage may increase, decrease, or change providers over time.

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4. How to Fill the Gaps with Health Spending Accounts (HSAs)

For employees facing coverage limits or exclusions, a Health Spending Account (HSA) is an excellent solution.

What is an HSA?

An HSA is a tax-free spending account that allows employees to pay for eligible healthcare expenses not covered by their group benefits plan. Employers contribute a set amount, and employees can use the funds for approved medical, dental, and vision expenses.

Benefits of an HSA:

✔ Covers Expenses Not Included in Traditional Plans – Including elective procedures, laser eye surgery, and custom orthotics. ✔ 100% Tax-Free for Employees – Unlike bonuses or salary increases, HSA reimbursements are not taxable income. ✔ Flexible & Employee-Controlled – Employees decide how to allocate their funds based on personal healthcare needs. ✔ Cost-Effective for Employers – HSAs offer a fixed-cost solution for managing healthcare expenses while reducing taxable payroll.

How Employers Can Implement an HSA

1. Determine Contribution Amounts – Employers allocate a set annual amount per employee.
2. Define Eligible Expenses – Customize the HSA to include relevant services.
3. Integrate with Existing Benefits – HSAs work best alongside traditional health plans.
4. Educate Employees – Provide training on how to submit claims and maximize HSA funds.

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5. Frequently Asked Questions

Q: Are cosmetic procedures covered under group benefits?

A: Generally, no. Cosmetic procedures (e.g., teeth whitening, elective plastic surgery) are usually excluded from standard plans but may be eligible under an HSA.

Q: Can I use my HSA to pay for my family’s medical expenses?

A: Yes! HSAs typically allow employees to use funds for spouse and dependent healthcare expenses.

Q: Do unused HSA funds roll over?

A: Some HSAs allow rollover of unused funds, while others have a use-it-or-lose-it policy at year-end.

Q: How much do employers typically contribute to an HSA?

A: Contributions vary, but many employers provide $500 to $2,500 annually per employee.

Q: What if I leave my job? Do I keep my HSA funds?

A: HSAs are employer-funded, so unused balances do not transfer if you leave the company.

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6. Conclusion: Maximizing Your Health & Dental Benefits

Understanding what’s covered and what’s not under your group health and dental benefits is crucial for making informed healthcare decisions. While traditional benefits cover many essential services, gaps exist—and that’s where Health Spending Accounts (HSAs) come in.

Employers looking to offer comprehensive and flexible benefits should consider integrating HSAs alongside their current plans to give employees greater control over their healthcare spending.

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