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OHIP+ excludes Ontarians with private coverage

OHIP+ excludes Ontarians with private coverage beginning April 1, 2019

OHIP+ provides universal coverage for Ontario Drug Benefit formulary drugs for Ontario children and youth under the age of 25. It has been in place since January 1, 2018.

OHIP+ provides universal coverage for Ontario Drug Benefit formulary drugs for Ontario children and youth under the age of 25. It has been in place since January 1, 2018. (O. Reg. 17/19) formalizing the eligibility changes are slated to come into effect on April 1, 2019.

Beginning April 1, 2019:

  • children and youth who do not have existing prescription drug benefits available through a private insurance plan will continue to receive coverage through OHIP+;
  • children and youth who have existing prescription drug benefits available through a private insurance plan will not receive any reimbursement under OHIP+.

Amendments to OHIP+

Children and youth (excluding social assistance recipients, recipients of home care, and residents of homes for special care or a community home for opportunity) with private insurance will continue to have the following options under the revised program.

  • Access to prescribed medicines through their private insurer.
  • Individuals or families who have significant out-of-pocket costs, despite having private insurance coverage, may apply for additional financial support through the Trillium Drug Program as was done prior to the implementation of OHIP+ on January 1st, 2018.

Definition of Private Insurance
For the purposes of the revised regulation, private insurance is defined as any type of private plan, program or account which could contribute to the cost of any drug product, regardless of whether:

  • the private insurance plan covers the particular drug for which coverage is sought,
  • the child or youth or another person captured under the private insurance plan is required to pay a co-payment, deductible, or premium, or,
  • the child or youth has reached their annual maximum under the private insurance plan and no further coverage is available.

Additional Information
In public information sessions, representatives of the Ministry of Health and Long-term Care have stated that:

  • A Health Care Spending Account (HCSA), though not specifically included in the definition of a private plan, will be considered a private plan for the purposes of OHIP+.
  • Private plan coverage will be determined at point-of-sale, where a pharmacist will be required to obtain verbal confirmation of the existence of private coverage. Transactional billing will be directed to OHIP+, a private insurer, or the individual accordingly.
  • Regarding the Exceptional Access Program (EAP), OHIP+ and private insurance carriers are endeavouring to create a smooth transition focused on minimal disruption to ongoing patient care. Individual carriers are providing communications on how EAP clients will be transitioned in their specific environments.
  • Some plans enable members to voluntarily opt-out of coverage during enrolment or life event. When a member has opted out, they will be considered not to have private coverage and will be OHIP+ eligible.  

We invite you to reach out to Aon as soon as possible, so we can work with you through the transition and determine the full impact of these changes on your benefits plan.