Physician Payment and Policy Ontario Health Insurance Program
Resource Manual for Physicians
 
2.   PHYSICIAN PAYMENT AND POLICY

2.1   Schedule of Benefits Overview

The Ministry of Health and Long-Term Care (MOHLTC) makes payments in accordance with the contents of the Schedule of Benefits ("the Schedule"). This lists approximately 5,000 medically necessary physician services and includes extensive preambles and notes that provide detailed conditions for insured services. Separate fee schedules also exist for other practitioners, private medical laboratories and independent health facilities. The physicians’ Schedule is a legal document authorized by the Health Insurance Act and is amended only by regulation. The Health Insurance Act, Regulation 552 also contains a listing of explicitly uninsured services (provided with the Schedule as Appendix A) and should be read in conjunction with the Schedule.

Changes to the Schedule are discussed with the Ontario Medical Association (OMA) and may include the addition of new services, deletion of obsolete services and redefinition of existing services. Individual physicians who wish to propose changes may submit proposals through their respective OMA section to the OMA Central Tariff Committee (CTC). The CTC recommendations which are formally endorsed by the OMA Council may then be considered by the ministry for incorporation into future editions of the Schedule.

The Health Insurance Act stipulates that only medically necessary services are insured. Sometimes, a service may be either insured or uninsured depending on the medical indications for the service. For some services, the appropriate indications have been explicitly included as conditions in the fee code definition. The physician must ensure that the appropriate indications are documented in the patient medical record for audit purposes.

For procedures that may be considered cosmetic, the Schedule requires that the physician obtain prior approval from the ministry (complete the Request for Approval of Payment for Proposed Surgery (form 0691-84). Such requirements are described either in notes adjacent to applicable fee code or in Appendix D of the Schedule of Benefits.

The ministry regularly distributes OHIP bulletins that give notice of Schedule changes or provide additional information on physician payment policies.

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