Health, Dental and Travel, Life, and RecoverEase Insurance

If you are a resident of Ontario, OHIP covers residents for medical services in hospitals, healthcare clinics and doctor’s offices. Benefits include diagnostics, surgeries, and services provided by a licensed physician that are considered medically necessary.

OHIP also covers emergency medical services for travel which is limited. Out of province coverage is available up to the same limit OHIP pays in Ontario which is currently a maximum of $400 a day for in hospital care, and $50 for a doctor’s visit. We all know that if you have a medical emergency in another country the cost of care can be extremely high, often in the thousands of dollars for one medical event. OHIP recommends that you purchase private travel insurance to assist with the cost of medical emergencies when travelling.

After your 65th birthday, OHIP offers some additional benefits.

• The Ontario Drug Benefit (ODB) covers about 5,000 of the over 10,000 prescription drugs prescribed by doctors today. However, you pay a $100 annual deductible, which means that you pay for the first $100 of your prescriptions every year beginning every August. You also pay for the dispensing fee on your prescriptions up $6.11 per prescription filled.

• Some people believe that the ODB will cover all of their prescription needs in retirement, however, we know at Victor that 48% of all of our health care claims are for prescription drugs alone.

• MROO health insurance covers prescription drugs after age 50, the $100 ODB deductible, and dispensing fees at 90% up to $7.00.

• Our $2,500 annual drug maximum in 2025 meets the needs of the majority of MROO policyholders and we review it annually to keep pace with inflation in drug costs.

• OHIP also pays for one eye exam every 18 months and physiotherapy services after hospitalization or outpatient surgery.

OHIP benefits are limited in scope and can change at any time. Government budgeting for health care only goes so far, each year and priorities for OHIP funding are subject to change. For example, funding long-term care, staffing for doctors, and nursing care. Over the years OHIP has stopped offering some benefits that you might expect OHIP to cover. OHIP has delisted chiropractic services and PSA tests unless medically necessary and has limited physiotherapy services and eye exams to residents over 65 and under 18 only.

Suspending OHIP Benefits in the Past:

• In 2019, emergency medical travel coverage while outside of Ontario wad delisted (reinstated 2020). This action was challenged in court and the Superior Court of Justice ruled that the government's move to eliminate the out-of-country travel program violated the portability pillar of the Canada Health Act and coverage has been reinstated. Under law you must be able to take the same OHIP benefits you have at home in Ontario, with you wherever you are in the world.

• In the fall of 2021 vision care services were unavailable to persons over age 65 for a limited time when optometrists took OHIP to task and demanded more for the OHIP services they were providing. In March 2023, the Ontario Association of Optometrists came to a funding agreement with OHIP that will increase payment to them, however, that agreement included a reduction in service. Beginning September 1, 2023 there will be a change in coverage for residents over age 65 and eye exams will be offered every 18 months instead of every 12 months – Implementing the New Optometry Services Agreement

• It’s important to have a health insurance plan that is updated annually to keep pace with OHIP changes.

• When OHIP delisted chiropractic services and PSA testing, MROO added this coverage under our health insurance plan.

Guaranteed Acceptance 

Most private health insurance plans offer guaranteed acceptance without disclosing your medical history when you enroll within 60 days of losing your employer group insurance plan. MROO has a 90-day guaranteed acceptance period after losing coverage in any health insurance plan. 

You can think about purchasing your own private health insurance plan when you: 

• No longer have coverage under an employer group insurance plan through your employer or your spouse.
• If you are worried about the cost of paying for the benefits and services that were covered under your employer group insurance plan, you will want to purchase your own health insurance plan to top up OHIP coverage. Choosing an effective date for your private health insurance plan that coincides with the termination date of your employer group insurance plan maintains continuity in health care insurance.
• Are no longer eligible under your spouse or partners employer group insurance plan.
• When your employer group insurance ends you may be able to get coverage under your spouse’s employer healthcare plan. If so, you don’t need two plans, and you can wait to purchase private health insurance when that health insurance plan ends.
• Paying medical bills becomes unmanageable.  
• If you find your health, dental and medical expenses when travelling are more than you expected, you might want to consider private health insurance before you reach age 81, as most plans do not offer enrollment beyond this age. The cost is in the form of a monthly premium for a comprehensive benefit package, which is a predictable and more manageable expense. 

Here are some things to consider when comparing plans: 

1. Does the plan offer the benefits that are important to you? 

2. Does the plan include the coverage you need? 

3. Can I afford this plan now and throughout my retirement? 

4. Can I keep my plan for life - and can my partner? 

Advantages of Standalone Plans: 

• Only buy the coverage that you need and if you find you don’t use a plan anymore, like travel insurance, you can terminate it without losing your health insurance. 

• MROO offers health, dental and travel in separate plans – dental and travel must be purchased at the same time as health insurance but can be terminated at any time. Keep in mind that there is no option to enroll again later. 

• We know from the MROO insurance plan that 50% of our health insurance policyholders also enroll in the dental insurance, and 50% of applicants take the annual travel insurance. 

Most plans have similar coverage for prescription drugs, hospital room, paraprofessional services such as chiropractic services or massage therapy, nursing care, medical equipment, vision care and ambulance services but they can vary in the amount of coverage offered. Consider just how much coverage you will use. 

Some plans offer higher limits than you might need. For example: the MROO plan has an annual maximum of $2500 per person in 2025. Other plans may offer a higher prescription drug annual maximum, but we know from experience that only 2% of our policyholders will ever claim more than our current annual maximum. We design our benefits to meet the needs of the majority of our policyholders in any given year. 

Quick Consultations and Prescription Renewals: Most visits through Maple are for quick consultations or to renew prescriptions, making it a practical option for managing your health needs efficiently and without incurring an expense for renewing your prescription over the phone. 

In summary, telemedicine is a crucial component of modern health care, and its inclusion in private health insurance plans enhances accessibility and convenience for patients.  

Plan premiums generally increase year over year due to inflation, claims experience and when benefits are enhanced. When researching plans, consider asking how much rates have increased in the last 5-10 years to determine the average rate increase on the plans you want to purchase.

• MROO health and dental insurance plans are reviewed annually, and benefits are enhanced whenever necessary to keep pace with the needs of our insured members. 

Age is a big factor in determining health insurance premiums. Most plans price their insurance in five-year age bands, for example 60-65, so your insurance rates go up every five years after your birthday. You pay more for the same insurance as younger plan members due to age. This is problematic particularly if you are living on a limited income. Likely you will need health care more as you age and you shouldn’t have to pay more just to keep your insurance.  

• MROO does not have age banding. Everyone pays the same rate regardless of age – whether you are 50 or 90.

• Non-age banding is a more equitable rating structure and it provides plan members with a more stable and predictable expense meaning that you’re more likely able to maintain your insurance throughout your retirement because it’s easier to budget long term - and it’s more affordable.

Some plans end or limit coverage at a certain age or they do not offer all insurance coverage for life, for example dental and/or travel coverage. It is important to know that most insurance plans are only offered up to age 80 so if your insurance ends at that age you will not be able to get health insurance for the remainder of your life and when you need it most as you are aging. Some plans end benefits for spouses or family members when the eligible plan member dies. In other plans, if the policyholder passes away, coverage for the surviving spouse may only continue for a year or two. Lifetime coverage for retirees & spouses is very important and you should look for a plan that offers coverage for life.  

MROO offers benefits for life for you and your spouse.

1. Group plans are designed for employees and the employer is the group policy contract holder who determines what benefits are offered. The employees who have coverage can refer to their coverage in an insurance booklet. Eligibility is based on employment, so employees usually lose their insurance benefits when they no longer work for the company or at a specific age such as 65 or 70. Some employers limit eligibility to full time workers only and not casual or part time staff.

2. Private health insurance plans can be purchased personally and they come in the form of an individual insurance plan or an affinity insurance plan. 

3. An affinity plan is a bit more like a group plan because it sponsored by a specific group, organization or association. Affinity Plans are available through insurance carriers who specialize in this insurance. Benefits are offered as a benefit of membership in an association and that association is the plan sponsor who promotes awareness of the plan to their members. The members of the association have an affinity to each other: such as university alumni, retired teachers, police or public service retirees. There are eligibility requirements to participate in these insurance plans to ensure the applicant is affiliated with the sponsoring association and there may be age or relationship restrictions such as spouse or family for enrollment and/or when benefits end.   With affinity plans, the policyholder is issued their own insurance policy and can cancel their insurance at any time. 

4. Individual plans are sold directly to consumer from the insurance company. You've seen them advertised on TV, you can google them, and they can be purchased from any leading insurance provider like Sun Life, Manulife and Green Shield.

• Insurance companies take on the risk of insuring that your claims will be paid for the insurance you purchase. They offer insurance benefits that suit their business portfolio: for example, life and health insurance or home and auto insurance. The insurance company adjudicates and pays claims. When you have a claim dispute you must take it up with them.
• The plan sponsor is the employer or affinity group who offers the insurance to their employees, retirees or members. Sometimes enrollment is mandatory, as with employer group insurance, or it can be voluntary, such as with an affinity plan. Under an affinity plan the sponsor promotes the plan to those eligible for the insurance offered.
• There can be an advisor or insurance program manager who helps the employer or association find the right insurance provider and works with them to design the right insurance plan for their employees or members.
• Plan administration and enrollments are either managed by the insurance program manager, a third-party administrator (TPA), when the insurance product is purchased directly from them, or “off the self”.

• Victor is MROO’s insurance manager who brings together preferred insurance solutions from multiple carriers, with comprehensive benefits that are competitive in the marketplace. Plans are designed specifically for our member needs. Victor has a full-time client service team to respond to MROO members and policyholder questions and provide assistance with enrollment.

• OMERS supports MROO advocacy and services: Preparing to Retire (omers.com)

The bottom line is that you want a plan that will help to pay for the things that you need, as well as be there to help with unexpected costs. 

MROO’s insurance plan is slightly different from other plans for seniors.

Specifically designed for OMERS retirees  

• Rates are not age or health related same rates for everyone in the same plan 

• Quick and easy online enrollment 24/7 

• You can apply for insurance anytime between ages 50 and 81 

• Once you are enrolled in any MROO plan you can keep it for life 

• When OHIP delists benefits MROO looks to add them to our plan 

• You and your spouse can enroll when you lose your employer benefits together or separately 

• And you and your spouse can keep your benefits for life