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Health Insurance in Ontario – Ontario Health Insurance Plan (OHIP)

May 14th, 2013 | By | Category: Insurance

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Health care in Canada is delivered through a publicly funded health care system, which is mostly free at the point of use and has most services provided by private entities. It is guided by the provisions of the Canada Health Act of 1984. The government assures the quality of care through federal standards.

Health is a state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity (World Health Organization, 1948)

The government does not participate in day-to-day care or collect any information about an individual’s health, which remains confidential between a person and his or her physician. Canada’s provincially based Medicare systems are cost-effective partly because of their administrative simplicity. In each province each doctor handles the insurance claim against the provincial insurer. There is no need for the person who accesses health care to be involved in billing and reclaim. Private insurance is only a minimal part of the overall health care system.

Ontario Ministry of Health and Long Term Care

The Ministry of Health and Long-Term Care is the Government of Ontario ministry responsible for administering the health care system – Ontario Health Insurance Plan (OHIP) – and providing services to the province of Ontario.

Ontario Health Insurance Plan (OHIP)

Ontario’s health care system is one of the best in the world. Ontarians who qualify can access a variety of health care services in their community. The ministry covers a wide range of health services; however, it does not pay for services that are not medically necessary, such as cosmetic surgery. OHIP pays for most basic medical and emergency services you receive anywhere in Canada as long as you need them for medical reasons. Most of your Ontario health benefits are covered across Canada. The province or territory you are visiting will usually bill the Ontario Ministry of Health and Long-Term Care directly for hospital and physician services. In Quebec, you may have to pay for physician services and then submit your receipt to your local ministry office for payment. For people travelling outside Canada, OHIP pays a set rate for emergency health services.

Health Services Covered by OHIP

  • Physicians: The ministry covers all insured medically necessary services provided by physicians. Physicians may bill you for uninsured services or if you miss an appointment or your health card is not valid. You may contact the ministry if you have questions about charges for uninsured services.
  • Other Health Care Providers: Services provided by podiatrists are partially covered under OHIP. The ministry pays part while you must pay for the extra costs. You may need to pay the full or partial cost of services provided by other health care providers, such as physiotherapists. You may contact the ministry if you have questions about services provided by other health care providers.
  • Dental Services in Hospital: The ministry pays for some dental surgery, when it is done in hospital. You must pay the cost of regular dental services in a dentist’s office.
  • Eye Care: An eye examination is covered by OHIP once a year for persons under 20 and those 65 and over. OHIP covers a major eye exam once every 12 months for persons aged 20 – 64 who have medical conditions requiring regular eye examinations (refer to OHIP Bulletin 8089 or to Changes to OHIP Coverage for Eye Care Services).

OHIP Coverage for Eye Care Services

Effective November 1, 2004, routine eye examinations provided by either an optometrist or physician, for patients aged 20 to 64 are no longer covered by OHIP. These individuals pay for this service or have the cost of examinations covered by private insurance.

Eye Care Services Covered

  • Changes do not affect seniors or those under age 20. People 65 years and older and under 20 will continue to have OHIP coverage for an eye examination once every 12 months.
  • Changes do not affect ophthalmology services for patients of any age with medical conditions or diseases affecting the eyes.
  • Persons receiving assistance under the Ontario Disability Support Program, Ontario Works or the Family Benefits Program continue to receive coverage for routine eye examinations once every two years.

Increased Coverage for People with Medical Conditions

OHIP is increasing coverage for patients aged 20 to 64 years with medical conditions affecting the eye. Patients can receive a regular eye examination once every 12 months. Prior to November 1, 2004, eye examinations were covered once every two years. Patients with any of the following conditions can go directly to their optometrist or physician to receive an OHIP insured eye examination: diabetes mellitus, glaucoma, cataract, retinal disease, amblyopia, visual field defects, corneal disease, strabismus. Patients aged 20 to 64 who have conditions not listed above may also be covered for a regular eye examination. They should discuss this with their primary health care provider.

OHIP Coverage for Physiotherapy Services

The government is making changes to OHIP coverage for physiotherapy services to improve access for people most in need. Effective April 1, 2005 government-funded physiotherapy services are available for people who are:

  • Seniors 65 and over
  • Aged 19 and under
  • Residents of long-term care homes at any age
  • Needing physiotherapy services in their home or after being hospitalized at any age
  • Ontario Disability Support Program, Family Benefits and Ontario Works recipients of any age

Changes don’t affect physiotherapy services currently provided by:

  • Hospitals
  • Community Care Access Centres
  • Workplace Safety and Insurance Board

The government will also expand services beginning in April so that more long-term care homes across Ontario are able to offer physiotherapy to residents. The government will also increase physiotherapy services in rural and northern communities. Ontarians aged 20 to 64 will continue to have access to coverage if they require physiotherapy after overnight hospitalization, if they require services in their home or if they reside in a long-term care home. All Ontario Disability Support Program, Family Benefits and Ontario Works recipients will be covered regardless of age. All other people aged 20 to 64 will no longer receive coverage for physiotherapy. Ontarians with private insurance should check to see if their plan has coverage for physiotherapy.

OHIP Coverage for Chiropractors

Effective December 1, 2004, chiropractic services are no longer covered by the Ontario Health Insurance Plan

Medical Services in Other Canadian Provinces and Territories

Most of your Ontario health coverage benefits can be used across Canada. The province or territory you are visiting will usually bill Ontario directly. If you have to pay for health services you receive in another part of Canada, you can submit your receipts to your local ministry office to be considered for reimbursement. Most of your Ontario health benefits are covered across Canada. The province or territory you are visiting will usually bill the Ontario Ministry of Health and Long-Term Care directly for hospital and physician services. In Quebec, you may have to pay for physician services and then submit your receipt to your local ministry office for payment. Prescription drugs from pharmacies, home care services, ambulance services and long-term care services provided in other provinces and territories are NOT covered.

Medical Services outside Canada

For people travelling outside Canada, the ministry pays a set rate for emergency health services. Emergency health services are those given in connection with an acute, unexpected condition, illness, disease or injury that arises outside Canada and requires immediate treatment. Ambulance services are NOT covered.

OHIP for Ontarians Travelling Outside Canada

If you are a resident of Ontario and you are insured under OHIP, you are entitled to very limited funding for a certain range of medical services when you are travelling outside of Canada. For this reason, you are strongly advised to purchase additional health insurance every time you leave Canada and ensure that the supplementary insurance you have purchased provides adequate coverage.

Ontario residents are encouraged to purchase supplementary insurance when traveling outside Canada as many emergency health services provided outside the country cost much more than OHIP may pay.

OHIP Eligibility

Ontario residents are eligible for provincially funded health coverage (OHIP). Generally, to be eligible for Ontario health coverage you must:

  • be a Canadian citizen, permanent resident or among one of the newcomer to Canada groups who are eligible for OHIP as set out in Ontario’s Health Insurance Act; and
  • be physically present in Ontario for 153 days in any 12-month period; and
  • be physically present in Ontario for at least 153 days of the first 183 days immediately after establishing residency in the province; and
  • make your primary place of residence in Ontario

You may be eligible for the Ontario Health Insurance Plan (OHIP) if you are included under one of the following categories:

  • you are a Canadian citizen, permanent resident or landed immigrant, or are registered as an Indian under the Indian Act;
  • you have submitted an application for permanent residence in Canada, and Citizenship and Immigration Canada has confirmed that you meet the eligibility requirements to apply for permanent residence in Canada;
  • you have applied for a grant of citizenship under section 5.1 of the Citizenship Act (Canada), and Citizenship and Immigration Canada has confirmed that you meet the eligibility requirements to apply for citizenship (i.e., children adopted internationally by Canadian citizens);
  • you are a “protected person” – i.e. a Convention Refugee or a person in need of protection;
  • you are a foreign worker who holds a valid work permit or other document issued by Citizenship and Immigration Canada (CIC) permitting you to work in Canada, and you also have a formal agreement in place to work full-time for an employer situated in Ontario which sets out the employer’s name, your occupation, and confirmation that you will be working for no less than six consecutive months;
  • you are a member of the clergy who is legally entitled to stay in Canada and will be providing services to a religious congregation in Ontario for at least six months;
  • you hold a Temporary Resident Permit with case type 80 (for adoption only), 86, 87, 88, 89, 90, 91, 92, 93, 94 or 95;
  • you are the spouse, or dependent child (under 22 years old or 22 years and over if dependent due to a mental or physical disability) of an OHIP-eligible member of the clergy or OHIP-eligible foreign worker;
  • you hold a valid work permit under the federal Live-in Caregiver Program;
  • you hold a valid work permit under the federal Seasonal Agricultural Worker Program

Tourists, transients or visitors are not eligible for OHIP coverage.

Your eligibility for Ontario health insurance coverage is based solely on:

  • you having one of the above OHIP-eligible citizenship or immigration statuses,
  • you making your primary place of residence in Ontario,
  • you meeting the physical presence requirements.

Everyone, including babies and children, must have their own health cards. Always carry your health card with you. You should be ready to show it every time you need medical services.

OHIP coverage normally becomes effective three months after the date you establish residency in Ontario. The ministry strongly encourages new and returning residents to purchase private health insurance in case you become ill during the OHIP waiting period.

Insurance for People Waiting for OHIP

Health Insurance for Newcomers

OHIP coverage normally becomes effective three months after the date you establish residency in Ontario. The ministry strongly encourages new and returning residents to purchase private health insurance in case you become ill during the OHIP waiting period.

How long can I be absent from Canada and still maintain my OHIP coverage?

You may be temporarily outside of Canada for a total of 212 days in any 12 month period and still maintain your OHIP coverage as long as your primary place of residence is still in Ontario. However, the ministry does have extended absence provisions which are outlined below.

Absences within Canada

If you are already insured by OHIP and choose to travel, work or study outside of Ontario but within Canada, you may be eligible for continuous Ontario health insurance coverage.

Absences outside Canada

You may be eligible for continuous OHIP coverage if you are away from Ontario for one of the following reasons :

  • Study full-time outside of Canada
  • Work outside of Canada
  • Charitable work outside of Canada

To be eligible for continuous OHIP coverage during one of these absences, you must first meet certain physical presence requirements. You must be physically present in Ontario for at least 153 days in each of the 2 consecutive years immediately before the absence.

Other Types of Absences

You may also be eligible for continuous OHIP coverage during a longer absence when you are away from Ontario for vacation or other reasons for up to 2-years at a time which may be taken as a full two-year absence or as two one-year absences. To be eligible for continuous OHIP coverage during your first absence of this type, you must typically be physically present in Ontario for at least 153 days in each of the 2 consecutive years before the absence.

You may be eligible to maintain your OHIP coverage during subsequent absences of this type. To be eligible for a further Vacation/Other Reason absence, you must meet the physical presence requirements in Ontario for at least 153 days in each of the 5 consecutive years before each subsequent absence.

How long will I be eligible for OHIP coverage during an extended absence?

OHIP coverage during an extended absence is provided in increments of one year, up to the maximum time allowed under each category of extended absence.

Reason Continuous OHIP Eligibility
Study Outside Canada Duration of a full-time academic program (unlimited)
Work Outside Canada Five-year terms (provided specific residency requirements are met for 2 years between each term)
Charitable Work Outside Canada Five-year terms (provided specific residency requirements are met for 2 years between each term)
Vacation/Other Reason Two-year terms (provided specific residency requirements are met for 5 years between each term)

 

Are longer absences permitted for my family?

In most cases, your spouse, or dependent children (under 22 years old or 22 years and over if dependent due to a mental or physical disability) can maintain their OHIP coverage while accompanying you on your extended absence for study, work, or charitable work.

You should obtain additional insurance coverage for your absence from Canada

The Ministry of Health and Long-Term Care of Ontario strongly recommends you, whether you are absent from Canada for a few minutes or for an extended time, to purchase additional health insurance every time you leave Canada to cover any expenses in excess of the limited funding provided by OHIP. OHIP does not insure or pay for all out-of-country medical services. Also, the amount of funding provided by OHIP will not usually cover the full cost of any health services that you do obtain outside of Canada. You should therefore, buy supplementary health insurance from a private insurance company to provide you with additional coverage for your trip. It is also recommended that you understand the terms and conditions of the additional insurance coverage you have purchased and the implications of any pre-existing health conditions on your insurance coverage.

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