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Ontario Health Insurance Plan (OHIP)

Ontario Health Insurance Plan (OHIP). A Summary for Ontario Medical Students. Acknowledgments.

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Ontario Health Insurance Plan (OHIP)

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  1. Ontario Health Insurance Plan (OHIP) A Summary for Ontario Medical Students

  2. Acknowledgments This module is the product of the efforts of Michael Kilianand Ryan Luther, two dedicated members of the Ontario Medical Students’ Association Political Advocacy Committee and medical students at the University of Toronto.

  3. Table of Contents 1. Eligibility 2. Summary of Services: • Insured services • Uninsured services • Drug coverage • Long-term care 3. Travel • Services while out of Canada • Services while out of Ontario • Services while out of province Canadians in Ontario 4. Subgroups • Services for new Canadians • Coverage for Aboriginals • Coverage for members of the military

  4. Eligibility

  5. Criteria for OHIP eligibility 1. Canadian citizen, permanent resident or a newcomer that is approved by the Ontario Health Insurance Act. AND 2.  Physically present in Ontario for 153 days in any 12 month period. AND 3.  Physically present in Ontario for at least 153 of the first 183 days immediately after establishing residency in the province. AND 4.  Make your primary place of residence in Ontario Care, M.o.H.a.L.T. Ontario Health Insurance Plan (OHIP).  2011  [cited; Available from: http://health.gov.on.ca/en/public/programs/ohip/.

  6. Summary of Services

  7. Insured Services The following services are covered: • All medically necessary services provided by physicians1 • Dental surgery if done in hospital 1 • One eye examination per year for individuals under 20 and over 65, or for people between 20-64 who have a medical condition requiring regular eye exams 2 • Ambulance services are covered, but patients must pay  $45.00. This fee can be waived in specific circumstances 3 • Some physiotherapy services 4 • Podiatry services are partially covered 1  Exceptions to the above insured services can be found at the following websites: 1: Care, M.o.H.a.L.T. Health Services. 2011 available from http://www.health.gov.on.ca/english/public/pub/ohip/services.html 2: Care, M.o.H.a.L.T. Changes to OHIP Coverage for Eye Services. 2011 available from http://www.health.gov.on.ca/english/public/pub/ohip/eyecare.html 3: Care, M.o.H.a.L.T. Ambulance Services Billing. 2011 available from  http://www.health.gov.on.ca/en/public/publications/ohip/amb.aspx 4: Care, M.o.H.a.L.T. Changes in Coverage for Physiotherapy Services. 2011 available from http://www.health.gov.on.ca/english/public/pub/ohip/physiotherapy.html

  8. Uninsured Services The following services are not covered: • Cosmetic surgery • Some physiotherapy services 2 • Dental services in a dentist’s office 1 • Eye exams for patients between 20 and 64, except for patients with specific medical conditions 3 • Services obtained at a non-licensed health facility • Preferred hospital accommodation unless prescribed by a physician • Private duty nursing service • Prescription renewals over the telephone • Completion of forms/certificates for work, school, fitness clubs or insurance • Testimony in court 1: Care, M.o.H.a.L.T. Health Services. 2011 available from http://www.health.gov.on.ca/english/public/pub/ohip/services.html 2: Care, M.o.H.a.L.T. Changes in Coverage for Physiotherapy Services. 2011 available from http://www.health.gov.on.ca/english/public/pub/ohip/physiotherapy.html 3: Care, M.o.H.a.L.T. Changes to OHIP Coverage for Eye Services. 2011 available from http://www.health.gov.on.ca/english/public/pub/ohip/eyecare.html

  9. Drug Coverage • OHIP only covers medications that are administered in a hospital. • Ontario offer six drug programs that assist in covering the costs of medications: Ontario Drug Benefit Program, New Drugs Funding Program for Cancer Care, Special Drugs Program, Inherited Metabolic Diseases Program, Respiratory Syncytial Virus Program for High-Risk Infants and the Visudyne Program.  • The Ontario Drug Benefit (ODB) Program covers the majority of medications on the ODB formulary, often with a financial contribution from the recipient. Eligibility criteria include: • Age 65 years or older • Resident of long term care home • Resident of Home for Special Care  • Receive professional services under the Home Care Program • Trillium Drug Program registrant • Receiving Ontario Works or Ontario Disability Support Program Justice, D.o. Canada Health Act. 2012 [cited; Available from: http://laws-lois.justice.gc.ca/eng/acts/C-6/page-1.html?term=necessary+medically+m%C3%A9dicaux+medical#s-2 Care, M.o.H.a.L.T. Ontario Drug Benefit : The Program.  2011  [cited; Available from: http://www.health.gov.on.ca/english/public/pub/drugs/odb.html.

  10. Long-Term Care • Long term care can take one of two forms: 1) at home 2) in an establishment • While still living at home, patients can receive care from visiting health care professionals, personal support workers, homemakers and have access to community support services. Patients must submit and application to the Community Care and Access Center (CCAC). • The CCAC will determine their eligibility for publicly funded services as well as select the necessary providers. If patients are not eligible for publicly funded support the CCAC can still assist in connecting the patient to the appropriate resources in the community.  Care, M.o.H.a.L.T. Seniors' Care : Home, Community and Residential Care Services for Seniors.  2011  [cited; Available from: http://www.health.gov.on.ca/english/public/program/ltc/ltc_mn.html. Care, M.o.H.a.L.T. Seniors' Care : Care in Your Home.  2010  [cited; Available from: http://www.health.gov.on.ca/english/public/program/ltc/8_home_comm_mn.html.

  11. Long-Term Care • If an individual wishes to move into a separate establishment for care, there are three options:  • Supportive housing,  • Retirement homes and  • Long-term care homes.  • For supportive housing, patients may be eligible for government subsidies to cover the cost of rent. Retirement homes on the other hand are not covered by the government • Long term care homes are meant for individuals who require 24 hour nursing care and supervision. Funding is available for long-term care homes but residents must also provide a co-payment.  Care, M.o.H.a.L.T. Seniors' Care : Residences Offering Care.  2010  [cited; Available from: http://www.health.gov.on.ca/english/public/program/ltc/12_residential_mn.htm Care, M.o.H.a.L.T. Seniors' Care : Long-Term Care Homes.  2011  [cited; Available from: http://www.health.gov.on.ca/english/public/program/ltc/15_facilities.html.

  12. Travel

  13. OutofCountry Services • To maintain OHIP coverage while out of Ontario, individuals must not be out of the province for more than 212 days in any 12 month period.1 • Individuals may be eligible for extended coverage during longer absences for: • Study outside of Canada • Work outside of Canada • Charitable work outside of Canada • If you require medical care while travelling, you are covered for the following amounts: • Emergency health services are covered up to $50.00/day. • Inpatient medical services are covered up to $200/day.  • Specialized services including surgery, coronary care, intensive care, neonatal or pediatric special care are covered up to $400/day.  • Outpatient dialysis services are covered up to $210/day.   1: Care, M.o.H.a.L.T. Traveling Outside Canada.  2010 http://www.health.gov.on.ca/en/public/publications/ohip/travel.aspx

  14. OutofCountry Services • The following services are not covered while out of the country: • Ambulance services • Services obtained at a non-licensed health facility • Services that are considered to be experimental, for research, or part of a study • Treatment for an illness that began while in Canada • It is recommended that all individuals purchase supplemental insurance while travelling

  15. OutofProvince Services • Most Ontario health coverage benefits can be used across Canada • Provinces will usually bill Ontario directly, but if you have to pay, you can submit the receipts for reimbursement • Note:  You will be reimbursed at OHIP rates. The OHIP rate may be less than the amount you were charged • Prescription drugs from pharmacies, home care services, ambulance services and long-term care services are not covered in other provinces Care, M.o.H.a.L.T. Traveling to Another Province or Territory Within Canada.  2010 http://www.health.gov.on.ca/english/public/pub/ohip/travel_another_province_territory.html

  16. Out of Province Canadians Coming to Ontario • One of the principles of the Canada Health Act is portability.  • This principles ensures that even if a resident moves to a different province or territory, they are entitled to receive health care coverage by their home province.  • Thus, Canadians can travel within the country with the same health coverage as they would enjoy in their home province. All that is required is that the individual present their provincial health care the same as a citizen of Ontario would present their OHIP card to a health care provider.  • However, the provision of "additional benefits" such as prescription drugs or air ambulance services are generally not portable outside one's home province or territory. Coverage for these services can be purchased from a private insurance provider. Canada, H. Canada Health Act - Frequently Asked Questions.  2011  [cited; Available from: http://www.hc-sc.gc.ca/hcs-sss/medi-assur/faq-eng.php#a8.

  17. Subgroups

  18. New Canadians • For newcomers to Canada, OHIP coverage becomes effective three months after residency is established.  • During these three months, newcomers must purchase private health insurance in order to receive health care coverage. Care, M.o.H.a.L.T. Ontario Health Insurance Plan (OHIP).  2011  [cited; Available from: http://health.gov.on.ca/en/public/programs/ohip/.

  19. Aboriginals • Aboriginal peoples living in Ontario are able to services insured by OHIP. • The Federal government also assists this population by providing health promotion programs and public health services on reserves or certain Inuit communities. If areas are out of reach of appropriate medical services the government of Canada provides both primary and emergency care services. • The First Nations and Inuit Health Branch (FNIHB) is responsible for delivering these services.  • Many aboriginal people are also provided non-insured health benefits including prescription medications, vision care, dental services and medical transportation. Shah, C., Public Health and Preventative Medicine in Canada. Fifth ed. 2003: Elsevier Saunders. Canada, H. Aboriginal Health.  2004  [cited; Available from: http://www.hc-sc.gc.ca/hcs-sss/delivery-prestation/fptcollab/2004-fmm-rpm/fs-if_02-eng.php

  20. Military • As stipulated under the National Defence Act, members of the Canadian military are covered by a separate, federally funded plan: The Canadian Forces Health Services (CFHS). Personnel are issued separate CF Health Cards to identify that they are part of this system. In ordinary circumstances, they must seek care from CF approved facilities unless it is a medical emergency. • OHIP-eligible family members who move to Ontario are eligible for immediate OHIP coverage if they are a spouse or dependant of either: Regular Force member of the Canadian Forces or a Reservist currently deployed by the Canadian Forces into active service. • A full list of health covereage for members of the Military can be found at: http://www.forces.gc.ca/health-sante/ps/guide/ehb-ssa-eng.asp Defence, N. About Us- Roles and Responsibilities.  2008  [cited; Available from: http://www.forces.gc.ca/health-sante/au-sn/roles-eng.asp. Defence, N. Understanding and Accessing Your Health Care Benefits.  2008  [cited; Available from: http://www.forces.gc.ca/health-sante/ps/guide/default-eng.asp.

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