Extended Health Benefits

Frequently Asked Questions

NOTE: The new EHB Policy does not apply to residents who access Non-Insured Health Benefits or Métis Health Benefits. Seniors will continue to receive the same benefit coverage under the new policy.

 

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Policy Changes and Benefits

Why is the government making these changes to the Extended Health Benefits Program?

The changes being made are to address gaps in coverage that left some NWT residents without access to important health benefits such as prescription drugs. The GNWT conducted a comprehensive review of coverage across various jurisdictions and sought feedback from residents and stakeholders. The updated policy aims to ensure fair access to extended health benefits for all NWT residents, with a focus on those with low income who were previously not covered under the existing policy.

What are the changes to the Extended Health Benefits Policy?

The new policy no longer requires residents to have a specified disease condition to access benefits. Instead, a suite of benefits is available, each with its own eligibility criteria and coverage levels. The changes to the policy include the introduction of an annual income assessment for benefit eligibility. Residents with earnings above the established low-income thresholds will need to contribute to the cost of their benefits, up to reasonable limits adjusted for family size (dependents) and region of residence to account for cost of living.

Public Engagement and Feedback

What changes were made to the proposed framework based on feedback received through public engagement and included in the new Extended Health Benefits Policy?

Based on the feedback received through public engagement, several changes were made to the proposed framework and are reflected in the new Extended Health Benefits Policy. These changes are:

  1. Removal of the requirement for residents to purchase third-party insurance and exhaust its drug benefits before being eligible for the EHB Drug Benefits. The EHB program continues to be the payor of last resort.
  2. Incorporation of support for residents above the low-income threshold to access medical supplies and equipment benefits through a cost-sharing model with reasonable family maximums.
  3. Revisions to the presentation of benefits in the policy. The benefits are now described in Schedules, which outline each benefit and its specific eligibility criteria, replacing the previous presentation of benefits as packaged programs based on eligibility.

Implementation of the Policy

When will the new policy come into effect?

The new Extended Health Benefits Policy will come into effect on September 3, 2024.

Work is underway to ensure a smooth transition. This includes setting up systems to manage information effectively, reviewing and updating administrative processes to make sure everything runs smoothly and efficiently, developing guidelines and documents to help everyone understand how the new policy will work, and training staff members so they can support the new policy and answer questions from residents.

Our goal is to improve access to health products and  services and ensure a seamless transition for everyone. We're committed to making this process as easy as possible.

Are the changes to the Extended Health Benefits Policy final?

Yes. The changes to the Extended Health Benefits Policy were made through a comprehensive review and engagement process and are now final.

A thorough research process was conducted, looking at similar programs across Canada and adapting them to better fit the unique needs of northern communities. Additionally public and stakeholder feedback was gathered and incorporated into the final policy.

When will the yearly benefit period start and end?

The yearly benefit period is 12 months. This 12-month period is between September 1 and August 31st.

Income Assessment and Fairness

How will my eligibility for benefits and the amount I need to pay be determined?

We will use income assessment to determine if you qualify for benefits and how much you will need to contribute based on your income. Our goal is to make sure the process is fair for everyone. Use the Extended Health Benefits Calculator to find out which benefits you may be entitled to, and to calculate your potential contribution based on your income.

What happens if my income falls below the low-income threshold?

If your income is below the established low-income threshold, you will have access to prescription drugs, dental care, vision care, and medical supplies and equipment benefits at no cost to you.

How are the cost sharing amounts determined, and will they consider my family size?

The cost sharing amounts are set at a reasonable rate based on the income assessment, taking into account the size of your family. We want to make sure it remains affordable for you.

How will the low-income threshold be determined, and will it be adjusted in the future?

The low-income threshold is determined by the current Northern Market Basket Measure (MBM-N). Adjustments will be made to this threshold to account for family size and the region of residence. We will review and adjust the income thresholds annually.  

What is being done to reduce the impact of changes to Extended Health Benefits for the first year?

To reduce the impact of changes in the first year, we have adjusted the cost sharing arrangements for income band levels from two to ten. If you fall within these income band levels, you will have access to eligible prescription drugs and medical supplies and equipment benefits at no cost to you.

If my income is below the low-income threshold, will I have to pay anything for prescription drugs and medical supplies and equipment benefits?

If your income is below the low-income threshold, you will not have to pay anything for dental, vision, prescription drugs and medical supplies and equipment benefits. These benefits are available to you without any cost.

Will the income thresholds be regularly reviewed and updated?

Yes, the income thresholds will be reviewed annually and updated as required.

What happens if my income changes during the year? Will my benefits be reassessed?

We understand that your income may change over time, and we want to be responsive to those changes. That's why we're developing a process to reassess income for residents whose income decreases by 10% or more during the year.

Are there family maximums for eligible prescription drug costs? How do they work?

Yes, there are annual family maximums for eligible drug costs. All out-of-pocket costs for eligible drugs for your family will count towards your family maximum. Once you’ve reached this amount, Extended Health Benefits will cover 100% or the remaining amount of eligible drug costs for your family, for the rest of the benefit year. These maximums ensure that you will not have to pay more than a certain amount out-of-pocket each year for your eligible drug expenses.

How does the cost-sharing model for eligible prescriptions drug work?

The cost sharing model for prescription drug benefits has three parts:

  1. A deductible, which is the amount you pay out of pocket before the drug plan starts covering costs. The deductible amount is based on your income assessment. Once you have paid out-of-pocket deductible amount you will move into the cost sharing.
  2. Once you reach the deductible, the drug plan will cost share by covering 70% of your prescription drug costs and you will pay the remaining 30% towards the cost of your prescriptions until you reach your family maximum amount.
  3. Once you reach the family maximum amount, the drug plan will cover 100% of your eligible prescription drug costs for the rest of the benefit year.

How does the cost sharing model for medical supplies and equipment benefits work?

The cost sharing model for Medical Supplies and Equipment Benefits involves Extended Health Benefits covering 75% of the cost, while you contribute 25%. As expenses can add up, family maximums have been set for each year, ranging from $500 to $1500, based on your family’s net income level. This ensures that costs stay reasonable for you and your family.

Are there family maximums for medical supplies and equipment costs based on income level?

Yes, there are family maximums for medical supplies and equipment costs. These maximums vary based on your income level and ensure that the costs remain reasonable for you and your family.

How does income assessment help ensure responsible use of public funds?

Income assessment is the most equitable way to ensure fairness. Good public policy is fair, equitable and sustainable. It is our responsibility to ensure public funds are used to support those in need.

Whose income will be included in the family income calculations for Extended Health Benefits?

You and your spouse’s income (if applicable) will be included in the family income calculations.

Individuals who live with you but are not included in your family income and benefit assessment: boarders, roommates, adult children (19 years and older), elderly parents, or guests will need to apply separately.

I still have an adult child living with me. Will their income be included in my family income calculations?

No. Once your child has reached 19 years of age they must apply for their own benefits.  Their income would be based on their Canada Revenue Agency’s (CRA) Income Statement as issued after personal income tax has been assessed.

If your child’s income falls under the low-income threshold, they would be eligible for Extended Health Benefits at no cost to them.

If your child’s assessed income is above the low-income threshold, they would need to pay any deductible/co-insurance amount assessed for drug and medical supply and equipment benefits, up to their family maximum amount.

My child is attending post-secondary school. Are they considered a dependent?

No. Children attending post-secondary school are not considered dependents.

Expansion and Access

Who is eligible under the Extended Health Benefits Policy?

To qualify for the new Extended Health Benefits program, you need to meet the following requirements:

  • Have a valid health care card from the Northwest Territories (NWT).
  • Not be eligible for Métis Health Benefits, Non-Insured Health Benefits.
  • You must also first seek reimbursement from your employer or any similar plans that provide drug, medical supplies and equipment, vision, dental, or transportation benefits.

Note: It is important that you review the detailed information for each benefit area to determine which benefits you are eligible to receive: New Extended Health Benefits Policy

What benefits are covered under the new Extended Health Benefits Policy?

Under the new Extended Health Benefits Policy, the following benefits are provided:

Drug Benefits:

  • Drugs that are on the NWT Pharmacare formulary.
  • Coverage for drugs not listed on the NWT Pharmacare formulary may be considered on an exception basis, with prior approval, and if they meet the following requirements:
    • a Health Care Prescriber provides clinical reasons for the request;
    • the NWT’s clinical consultant recommends approval for the drug; and
    • the drug has received a positive recommendation from the Canadian Agency for Drugs and Technologies (CADTH)

Medical Supplies and Equipment Benefits:

Vision Care Benefits:

Dental Benefits:

  • Coverage for dental services and products listed in the Non-Insured Health Benefits Dental Benefits Guide and the Northwest Territories NIHB Regional Dental Benefit Grids.
  • Specific coverage for eligible individuals with assessed income below the established low-income threshold, those assessed and registered at a Canadian Cleft Lip/Palate clinic, and individuals aged 60 years and older.
  • Prior approval is required for certain treatments.

Extended Health Travel Benefits:

  • Coverage for travel expenses associated with accessing eligible benefits under Medical Supplies and Equipment Benefits and Dental Benefits.
  • Eligible individuals must have a valid referral from a Health Care Prescriber.

Please refer to the provided link to find specific details, limitations, and conditions of coverage for each benefit: New Extended Health Benefits Policy

Will the new Extended Health Benefit Policy result in increased eligibility and access to benefits?

Yes, the changes aim to make more residents eligible for benefits and reduce financial barriers. This will help support better health outcomes in the long term.

Application Process

Who can apply for the new Extended Health Benefits Program?

To apply, you must:

I am currently under the Extended Health Benefits for Specified Disease Conditions Program. Do I need to apply?

Yes. You must apply for the new Extended Health Benefits Program before July 31, 2024, to avoid gaps in coverage.

I am currently under the Extended Health Benefits for Seniors Program. Do I need to apply?

No. You do not need to apply. Your coverage remains unchanged.

What is the yearly benefit period?

The yearly benefit period from September 1 to August 31. You must re-apply annually by July 15 to ensure uninterrupted coverage.

Note: Seniors aged 60 and older are not required to re-apply annually.

How do I apply for the new Extended Health Benefits Program?

Complete all required sections of the EHB Application Form and include all necessary documentation. This is what you need to provide:

  • Household Information: List all family members. If newly widowed, include a copy of the death certificate. If newly separated or divorced, include a copy of your legal separation agreement or divorce certificate.
  • Insurance Information: Provide details for any household member’s work, school, or private insurance plans. If you have reached your insurance plan’s maximum, include a letter from the insurance company with the date the maximum was met and the reinstatement date.
  • Last Year’s Net Income: If you or your spouse are 59 years or younger, provide both Notices of Assessments/Reassessments, and complete Section 3 with the net income from line 23600 of your tax return. If you or your spouse has a Registered Disability Savings Plan, provide information from line 12500. Note: Your dependents’ income should not be included.

Send the completed form and required documentation to the Health Services Administration Office by:

  • Email: healthcarecard@gov.nt.ca
  • Regular mail: Department of Health and Social Services Registrations, Bag #9, Inuvik NT X0E 0T0
  • Fax: 1-867-777-3197

What happens after I submit my application?

The Health Services Administration Office will review your application for completeness. If it is incomplete, they will contact you for further information. Incomplete applications may delay your access to benefits.

Once the review is completed, you will receive a notification by mail detailing the benefits you are eligible for.

If you have been assessed as being eligible, you will receive an Alberta Blue Cross (ABC) welcome package, which includes an ABC ID card to be presented when accessing benefits.

What should I do if my household situation changes?

Complete the EHB Program Reassessment Form if your income decreases by 10% or more during the year or your family unit changes. This includes adding a new dependent or if you become newly widowed, separated, or divorced. Include the appropriate documentation (death certificate, legal separation agreement, divorce certificate, etc.) with your application to reflect these changes.

Support and Transition

I have kids. Do we get benefits as a family?

Yes. If you have children under the age of 19, they will get benefits as a family when you access the Extended Health Benefits Program. If your family's income falls below the established low-income threshold, you can access the program at no cost. However, if your family's income is above the low-income threshold, you will be required to pay a reasonable cost-share based on your family’s net income.

Please note that if your children are 19 years of age or older they will need to apply separately for the Extended Health Benefits Program.

I have health benefits through my employer or spouse, am I still eligible for benefits under the Extended Health Benefits Program?

Residents who have exhausted all their health benefits through their employer’s, spouse’s or other insurance plan can access the Extended Health Benefits Program.

Their family income will be assessed to determine if any cost sharing amounts must be paid, before being able to access the program.

Residents who have access to third party insurance, and do not use their benefits are not eligible for coverage.

I am a senior. Will these changes affect my benefits?

At this time, there will be no changes to the Seniors benefits.

I am fully covered under the Specified Disease Conditions Program now.  How will these changes impact my coverage for drugs and medical supplies and equipment?

If your adjusted family income is under the low-income threshold, you and your family members will be eligible for vision, dental, drug and medical supplies and equipment benefits at no cost.

If your adjusted family income is above the low-income threshold, you will be eligible for drug and medical supplies and equipment benefits.  You will need to pay a portion of your drug costs through a deductible and cost-share payment, and a portion of your medical supplies and equipment costs, up to your family maximum amounts. The cost share amounts, and family maximums depend on your family’s net income level.

If you or your family has access to drug and medical supplies and equipment benefits through private or employer insurance, those benefits must be used first.

Why can’t we keep the Specified Disease Conditions Program?

The Specified Disease Conditions Program is outdated and limited to a small number of specific conditions, which is discriminatory for residents with conditions not listed.  

The new policy shifts away from relying solely on clinical diagnosis and instead ensures that benefits are accessible to a wider range of people in a fair and equitable manner.

I am currently eligible under the Specified Disease Conditions Program, and require costly medical supplies and equipment, but I am not considered low-income. Does this mean I now have to pay for this equipment out of pocket?

Yes. If you are not considered low-income, you would be required to pay a portion of the cost for the medical supplies and equipment.

You will be required to pay 25% per eligible item, while Extended Health Benefits Program covers 75%, up to your family maximum.

Family maximums for medical supplies and equipment have been set for each year, ranging from $500 to $1500, based on your family’s net income level. This ensures that costs stay reasonable for you and your family.

If you or your family has access to medical supplies and equipment benefits through private or employer insurance, those benefits must be used first.

Prescription Drug Coverage

What if my doctor prescribes a drug not listed on the NWT Pharmacare formulary?

Coverage for drugs not listed on the NWT Pharmacare formulary may be considered on an exceptional basis, with prior approval, if they meet the following requirements:

  • a Health Care Prescriber provides clinical reasons for the request including evidence that the patient has tried all equivalent approved drugs and has failed to achieve a positive therapeutic outcome;
  • the NWT’s clinical consultant recommends approval for the drug; and
  • the drug has received a positive recommendation from the Canadian Agency for Drugs and Technologies (CADTH)

What does “exhausting” Drug Coverage through my insurance plan mean?

The drug coverage under your insurance plan would be considered exhausted if you:

  • Reach the annual coverage limit or lifetime maximum for a certain drug under your third-party plan
  • A specific drug is not covered under your third-party plan

Any eligible out of pocket cost-share for prescription drugs, or eligible costs for prescription drugs paid in full as a family, may be used toward the family deductible and family maximum amounts assessed under the Extended Health Benefit Program.

Travel Benefits

How does Extended Health Travel Benefits work?

The Extended Health Benefits Policy provides some travel benefits to eligible residents meeting specific criteria.

  • Seniors (aged 60 and over) receive 100% coverage for prior-approved travel needed to accessing insured health services, medical supplies, equipment, and dental benefits.
  • Other residents who meet the eligibility criteria for Medical Supplies and Equipment or Dental Benefits, and who need to travel to access those benefits, receive 100% coverage for prior-approved travel.

If you don’t meet these criteria, you can access medical travel benefits through the NWT Medical Travel Policy 49.06 and corresponding Ministerial Policies.  

Regardless of which Policy (EHB or Medical Travel) you access, benefits include:

  • Coverage for travel to and from the nearest centre, plus stay at a boarding home, organized by the Medical Travel Office, including meals, accommodation, and transportation.
  • In communities without a boarding home, the Medical Travel Office will arrange hotel stays, meals, and local transportation.
  • If you choose not to stay at the boarding home, you must arrange your own meals, accommodation, and local transportation. We reimburse up to $50 per approved person per night for accommodation and $18 per approved person per day for meals. Reasonable local transportation costs to airport, accommodation, pharmacy, and appointments may also be approved.

Residents currently covered under the Specified Disease Program for medical travel will fall under the NWT Medical Travel Policy once the new EHB Program starts. This means that if you are above the low-income threshold, you will need to pay a portion of eligible medical travel expenses.

Who is considered low-income under the Medical Travel Policy?

To be considered low-income under the Medical Travel Policy:

  • You must have an income of $70,000 a year or less.
  • If you are married or in a common-law relationship, your combined income must be $85,000 a year less.
  • If you have one or more children under 19 living in your household, your combined income must be $100,000 a year or less.

I make more than the low-income threshold, but my circumstances prevent me from affording medical travel. What can I do?

If you make more than the low-income threshold but can’t afford to pay a portion of the medical travel expenses due to your unique circumstances, you can apply for an exception. This is what you need to do:

  • Have a valid NWT Health Care Card.
  • Be eligible for Medical Travel Benefits under the Medical Travel Policy.
  • Have a valid Medical Referral from an NWT Health Care Provider to the nearest center.
  • Provide details about your extraordinary health needs or financial hardship.
  • Complete and submit the Medical Travel Exception Request Form.

Send your completed form to:

We will review your situation and determine if you qualify for additional support to cover your medical travel expenses.