Do You Know These Important OHIP Coverage Details?

Karen Taylor Smith is the Senior Manager, Group Benefits at The Benefits Trust. She has worked with The Benefits Trust since 1997, using her deep knowledge of employee benefit plans to customize the right solutions for businesses. Karen speaks, blogs, and contributes regularly to various media outlets on group benefits and compensation topics.

Do You Know These Important OHIP Coverage Details?

Do you and your employees know all the ins and outs of the Ontario Health Insurance Plan (OHIP)? If you’re not in the healthcare or benefits industry, chances are that you don’t.

And you might be missing out on some great coverage options!

Benefits plans are designed to wrap around provincial medicare programs like OHIP. Therefore, it’s worthwhile for employers and employees to understand the OHIP programs available to ensure they’re getting all the coverage they’re eligible for.

Here are four OHIP coverage details that you might have overlooked:

OHIPRoutine Eye Exams Are Covered for Children, Seniors, and Adults with Specific Medical Conditions

As you probably know, OHIP no longer provides coverage for routine eye exams for people between the ages of 20 and 64.

However, you may not be aware that patients aged 20 to 64 with certain conditions are still eligible for their eye exams to be covered by OHIP.

Here are the conditions which would allow you to receive OHIP insured eye exams, even if you are within the age range not typically covered:

  • Amblyopia
  • Cataract
  • Corneal disease
  • Diabetes mellitus
  • Glaucoma
  • Optic pathway disease
  • Recurrent uveitis
  • Retinal disease
  • Strabismus
  • Visual field defects

Some other conditions not listed may also be covered, so be sure to ask your doctor or ophthalmologist if you are unsure.

If you want more details about OHIP coverage for eye care services, you can click here for more information from the Ontario Ministry of Health and Long-Term Care.

The Ontario Drug Benefit Program Has an Exceptional Access Program

The Ontario Drug Benefit (ODB) Program covers seniors (age 65 or older), people living in long-term care or special care homes, or those receiving social assistance through Ontario Works or the Ontario Disability Support Program.

For these people, ODB covers the majority of costs for certain drugs (as well as some nutrition products and diabetic testing agents).

You should know that if the drug you need is not on the list – called the “Formulary” – you may still be able to access it (given that you are covered by ODB in the first place). You can apply for coverage for prescription drugs not on the approved list through the Exceptional Access Program (EAP).

Here’s how the EAP works:

  • You have tried drugs that are covered by ODB and they have not been successful OR you cannot use the covered drugs for some reason
  • Your Ontario doctor submits a request for an alternative drug to be covered by EAP
  • Your doctor’s request is reviewed and approved by the EAP

If you want more details about the Exceptional Access Program, you can click here for more information from the Ontario Ministry of Health and Long-Term Care.

The Ontario Drug Benefit Program Offers Supplemental Coverage through the Trillium Drug Program

In addition to those categories of Ontarians mentioned above, ODB provides benefits to people who are registered in the Trillium Drug Program (Trillium).

Trillium provides assistance for Ontarians who have high prescription drug costs relative to their household income. This is a great option for people who don’t have health coverage through their employer or whose health coverage is limited (for example, if you require $30,000 of prescription medication annually but your health coverage has a $5,000 maximum drug limit).

People participating in Trillium must pay a yearly deductible based on their total household income. Although it can vary, it is typically around 4% of your net income.

If you are paying for a lot of prescription medication out of pocket despite any coverage you have, you may want to consider registering for Trillium.

If you want more details about the Trillium Drug Program, you can click here for more information from the Ontario Ministry of Health and Long-Term Care.

The Assistive Devices Program Provides Funding for a Wide Range of Medical Equipment, Supplies, and Aids

OHIP offers the Assistive Devices Program (ADP), which is designed to provide additional funding for a variety of different medical devices needed by people with long-term physical disabilities.

Here is a high level overview of the types of supplies that are covered:

  • Communication Devices
  • Diabetic Supplies
  • Enteral Feeding Equipment and Supplies
  • Hearing Devices
  • Orthotic Devices
  • Ostomy Supplies
  • Pressure Modification Devices
  • Prosthetic Devices
  • Respiratory Equipment and Supplies
  • Visual Aids
  • Wheelchairs, Positioning, and Ambulation Aids

Usually, the provider of these supplies will help patients obtain their ADP funding. However, it is important for individuals to be informed about the help available to them to ensure they don’t overlook benefits they are eligible for.

If you want more details about the Assistive Devices Program, you can click here for more information from the Ontario Ministry of Health and Long-Term Care.

Know Your Benefits!

We encourage you to take the time to learn about all the healthcare benefits available to you through OHIP to ensure you receive the full coverage you are eligible for when you need it – and to help you and your employees manage healthcare costs effectively.

>> The Benefits Trust provides a wide range of benefit plan options to suit any organization’s needs. Contact us today!

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