Pangaea Express: OHIP+ FAQs

March 14, 2019

By Beverley HerczeghMarla Weingarten

The Ministry of Health and Long-Term Care released a list of FAQs for Ontario patients to better understand the upcoming changes of OHIP+, that are to be implemented April 1, 2019.

The government is focusing OHIP+ benefits on children and youth who do not have a private plan. The previous Liberal Health Minister had positioned the government as first payer for ANYONE 24 and under. The PC government has now redesigned this program to bring private insurers back as the first payer with the government only paying for those 24 and under without coverage.

So, Ontario children and youth who are currently OHIP-insured AND who do not have a private plan, will continue to receive coverage for eligible prescription medications through OHIP+.

Children and youth 24 years and under who have a private plan WILL NOT be eligible for OHIP+ even if:

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

The Ministry wants to remind households with high out-of-pocket prescription drug expenses, that include children and youth who are covered under a private plan, they can apply to the Trillium Drug Program.

There will be no transition period. Once the changes take effect on April 1, 2019, patients 24 years of age and under who have a private plan will no longer be eligible for the ODB program under OHIP+.

Children and youth on exceptional access program (EAP) drugs will need to complete any required insurer documentation before April 1, 2019 to secure private coverage. The Ministry is working with the Canadian Life and Health Insurance Association (CLHIA) and its member companies to ensure that a transition back to private plans minimizes disruption to recipients and administrative burden to clinicians. Patients are encouraged to contact their private insurer for details.

An FAQ list specific to pharmacists with Health Network System (HNS) changes and coding for claim submissions was also provided.

With no transition period to adjust, how exactly, will patients, who were on EAP, get this important message to reach out to their insurers for proper documentation? Hopefully those patients with private plans that require prior authorization will not be caught with disruption to their coverage. While the Trillium program can be used for those with large out-of-pocket costs, the CLHIA is suggesting the government automate drug claims through Trillium, given the current arduous, complex process for all involved, including insurers, pharmacists and most of all patients.(1) How does a pharmacy know if a patient has private coverage? They just ask them and take them at their word. The MOHLTC promises no clawbacks to pharmacy where misinformation was provided by patients.

For more information, please contact Bev Herczegh or Marla Weingarten.

(1) Read the CLHIA letter to the MOHLTC