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Policy Changes and Benefits

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

The changes are being made to address gaps in coverage that left some NWT residents without access to extended health benefits. 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 to all residents, 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. As part of our implementation, we are also looking at whether regional income thresholds are needed to make sure the program is affordable for residents.

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 1, 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 healthcare 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 will be a defined as 12-months. This 12-month period will be between July 1st and June 30th.

Income Testing and Fairness

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

We will use income testing to determine if you qualify for benefits and how much you will need to pay based on your income. Our goal is to make sure the process is fair for everyone.

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

If your income is below the established low-income threshold, you won’t pay anything when accessing benefits.

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

The cost-sharing amounts are set based on a reasonable 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 will be determined by averaging income levels in different regions. Adjustments will be made to this threshold to account for family size. We will review and adjust it every year based on the Northern Market Basket Measure to ensure it remains fair and accurate.

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 won't have to pay anything for dental, vision, prescription drugs and medical supplies and equipment benefits. These benefits are available to you without any cost. Adjustments will be made to this threshold to account for family size.

Will the income thresholds be regularly reviewed and updated?

Yes, the income thresholds will be regularly reviewed and updated. We will consider changes in the economy and make adjustments to ensure they remain fair and reflective of the current circumstances.

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

We understand that your income can change over time, and we want to be responsive to those changes. That's why we're exploring ways to reassess your income if it changes during the year. This means that if your income situation changes, you can have your eligibility reviewed to make sure you're still getting the support you need.

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% of eligible drug costs for your family, for the rest of the benefit year. These maximums ensure that you won't have to pay more than a certain amount 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 established based on your income assessment. You will pay 100% of your prescription drug costs up to the deductible amount.
2. Once you reach the deductible, the drug plan will cover 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 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 the Extended Health Benefits Program 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 testing help ensure responsible use of public funds?

Income testing helps us ensure responsible use of public funds by allocating benefits based on financial need. It ensures that those who require the most support receive it, while using public funds in an efficient and equitable manner.

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

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

These individuals who live with you are not included in your family income and benefit assessment: boarders, roommates, adult children (19 years and older), elderly parents, or guests. They will need to apply separately for the Extended Health Benefits Program.

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 under the Extended Health Benefits Program.  

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 the Extended Health Benefits Program 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 under the Extended Health Benefit Program for drug and medical supply and equipment benefits, up to their family maximum amount.

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 health, 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 exceptional 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:

• Coverage for prescribed medical supplies and equipment listed in the Non-Insured Health Benefits' Medical Supplies and Equipment Guide and Benefit List
• Freight/shipping expenses for eligible medical supplies and equipment.

Vision Care Benefits:

• Coverage for vision care services and products listed in the Non-Insured Health Benefits' Guide to Vision Care Benefits and NIHB Regional Vision Care Fee Grid NWT.

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.

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 proposed 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 Program or their 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 under the Extended Health Benefits Program 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 co-insurance payment, and a portion of your medical supplies and equipment costs through a co-insurance payment, 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 people with specific conditions, which is discriminatory for residents with conditions not listed.  

The goal of the new policy is to shift away from relying solely on clinical diagnosis and instead ensure that extended health 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 a co-insurance amount of 25% per eligible item, while Extended Health Benefits 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 Phamacare 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;
• 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 for all drugs under your plan
• Reach lifetime maximum for specific drug(s)
• Reach annual maximum for specific drug(s)
• If you reach your limit for a specific drug, you may be eligible for drug benefits for that specific drug.  However, you would still be required to use your private insurance for the remaining prescriptions (coordination of benefits) until the rest of your drug insurance coverage was exhausted.

Each family member would need to exhaust their own drug coverage under their insurance plan, before being eligible under the Extended Health Benefit Program. This may mean that some family members are covered under the GNWT plan before others.

Any eligible out of pocket co-insurance costs 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.

For drugs not covered under your private or employer sponsored health insurance plan, there will be a process to assess their eligibility under the Extended Health Benefit Program.