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Ontario Health Insurance Plan

OHIP Bulletins


INFOBulletin

Keeping Health Care Providers informed of payment, policy or program changes

To: Primary Care Physicians

Published by: Negotiations Branch, Claims Services Branch, Ministry of Health and Long-Term Care

Date Issued: March 28, 2019

Bulletin Number: 11208

Re: 2017 Physician Services Agreement – Phase One Award

Posted Electronically Only

PDF Version


The 2017 Physician Services Agreement – Phase One Award between the Ministry of Health and Long-Term Care and the Ontario Medical Association (OMA) includes provisions to remove the 0.50%, 2.65% and 1.30% payment discounts effective April 1, 2019. Details on these changes are provided below.

Removal of Physician Payment Discounts

Effective April 1, 2019 the discounts will be ended for clinical payments under the various primary care agreements, including physician payments for salary, sessional, per diem and capitation-based mechanisms.

The discounts will no longer be applied where the service date of the claim or payment is April 1, 2019 or later. Where the service date of the claim or payment is prior to April 1, 2019, the appropriate discount(s) will continue to be applied.

Primary Care models and programs affected by this change:

  • Aboriginal Family Health Team (AFHT)
  • Aboriginal Health Access Centres (AHAC)
  • Blended Salary Model (BSM)
  • Blended Salary Model (BSM) – Income Stabilization
  • Community Health Centres (CHC)
  • Comprehensive Care Model (CCM)
  • Family Health Group (FHG)
  • Family Health Network (FHN)
  • Family Health Network (FHN) – Income Stabilization
  • Family Health Organization (FHO)
  • Family Health Organization (FHO) – Income Stabilization
  • Family Health Team Specialists Sessional Groups (FHTSSG)
  • General Practitioner Focus Practice – Care of the Elderly Model 1 (GPFP-COE1)
  • General Practitioner Focus Practice – Care of the Elderly Model 2 (GPFP-COE2)
  • General Practitioner Focus Practice – Human Immunodeficiency Virus (GPFP-HIV)
  • General Practitioner Focus Practice – Palliative Care (GPFP-PC)
  • Group Health Centre (GHC)
  • Group Health Centre (GHC) - Specialists
  • New Graduate Entry Program (NGEP)
  • Rural and Northern Physicians Group Agreement (RNPGA)
  • Sioux Lookout Regional Physicians Services Inc. (SLRPSI)
  • St. Joseph’s Health Centre (SJHC)
  • Toronto Palliative Care Associates (TPCA)
  • Inner City Health Associates (ICHA)
  • Shelter Health Network (SHN)
  • Sherbourne Physician Group (SPG)
  • Weeneebayko Area Health Authority (WAHA)

Comprehensive Care Capitation and Comprehensive Care Capitation Reconciliation

Comprehensive Care Capitation payments for patient enrolment periods effective April 1, 2019, or later will no longer have the 3.15% discount applied.

Comprehensive Care Capitation reconciliation adjustments for patient enrolment periods up to 12 months prior to April 1, 2019, that are processed and paid after April 1, 2019, will continue to have the 3.15% discount applied.

Comprehensive Care Capitation Reduction (Roster > 2400)

The Comprehensive Care Capitation Reduction is applied to physicians who receive comprehensive care capitation payments and who have a roster size greater than 2,400 patients.

Comprehensive Care Capitation Reductions for patient enrolment periods effective April 1, 2019, or later will no longer have the 3.15% discount applied.

Comprehensive Care Capitation Reduction is not currently reconciled or adjusted for prior periods; therefore the discount will continue to not apply for periods prior to April 1, 2019.

Base Rate Capitation and Base Rate Capitation Reconciliation (Including Long-Term Care Capitation)

Base Rate Capitation payments for patient enrolment periods effective April 1, 2019 or later will no longer have the 3.15% discount applied.

Base Rate Capitation reconciliation adjustments for patient enrolment periods up to 12 months prior to April 1, 2019, that are processed and paid after April 1, 2019, will continue to have the 3.15% discount applied.

Base/Base Salary Payment

Effective for periods April 1, 2019 or later, physicians affiliated to a primary care model who receive Base/Base Salary Payments, annual compensation pro-rated and paid on a monthly basis, will no longer have the 3.15% discount applied.

Base/Base Salary Payments and base/base salary payment adjustments for periods prior to April 1, 2019, that are processed and paid after April 1, 2019, will continue to have the 3.15% discount applied.

Access Bonus Payment

Effective April 1, 2019, Access Bonus Payments, calculated as a percentage of a physician’s monthly Base Rate Capitation payment (Family Health Network (FHN), Family Health Organization (FHO), Group Health Centre (GHC)) or Base Payment (Blended Salary Model (BSM)) minus any outside use, will no longer have the 3.15% discount applied.

Access Bonus reconciliation adjustments for patient enrolment periods up to 12 months prior to April 1, 2019, that are processed and paid after April 1, 2019 will not have the 3.15% discount applied.

Sessional Payments

Effective for periods April 1, 2019 or later, physicians affiliated to a primary care model who receive compensation through Sessional Payments paid on a monthly basis, will no longer have the 3.15% discount applied.

Sessional Payments and Sessional Payment adjustments for periods prior to April 1, 2019, that are processed and paid after April 1, 2019, will continue to have the 3.15% discount applied.

Fee-for-Service Payments

Fee-for-Service claims with a service date of April 1, 2019, or later will no longer have the 4.45% discount applied.

Fee-for-Service claims with a service date of March 31, 2019, or prior that are processed and paid after April 1, 2019, will continue to have the 4.45% discount applied.

Primary Care Fee For Service Q codes

Primary Care Q code claims with a service date of April 1, 2019, or later will no longer have the applicable discount applied.

Primary Care Q code claims with a service date of March 31, 2019, or prior, that are processed and paid after April 1, 2019, will continue to have the applicable discount applied.
The following Q codes will have the 3.15% discount removed effective April 1, 2019:

  • Q014A – Newborn Episodic
  • Q015A – Newborn Episodic
  • Q042A – Smoking Cessation Counselling
  • Q050A – Heart Failure Management Incentive
  • Q060A – HIV (Human Immunodeficiency Virus) Monthly Management Fee
  • Q150A – FOBT (Fecal Occult Blood Test) Management Fee
  • Q302A – Sessional – Primary Care Services
  • Q303A – Sessional – Psychiatric Services
  • Q304A – Sessional – Internist Services
  • Q305A – Sessional – Primary Care After-Hours

The following Q codes will have the 4.45% discount removed effective April 1, 2019:

  • Q012A – After Hours Fee
  • Q016A – CCM (Comprehensive Care Model) After Hours Fee
  • Q017A – HIV (Human Immunodeficiency Virus) After Hours Fee
  • Q018A – GP (General Practitioner) Focus – COE1 After Hours Fee
  • Q590A – Basic Flu Shot - Fee For Visit Premium

Automated Premium Payments

Automated Premium payments (see list below) for services as of April 1, 2019, or later will no longer have the 4.45% discount applied.

Automated Premium payments for services prior to April 1, 2019, that are processed and paid after April 1, 2019, will continue to have the 4.45% discount applied.

  • Geriatric Age Premiums
  • Paediatric Age Premiums
  • Holiday Premium (Rural and Northern Physicians Group Agreement Groups/Physicians)
  • Seasonal Premium (Rural and Northern Physicians Group Agreement Groups/Physicians)
  • Specialist Shadow Billing Premiums (Family Health Team Specialists Sessional Groups)
  • GP (General Practitioner) Psych Premiums
  • Anaesthetic Age Premiums
  • Focus Practice Premiums
  • Geriatric House Call Premiums

Automated Blended Fee-For-Service Premium and Blended Premium on Age Premium

The 4.45% discount on Blended Fee For Service and Blended Fee For Service premium on Age Premiums for services provided on or after April 1, 2019, will no longer be applied.

The 4.45% discount on Blended Fee For Service and Blended Fee For Service premium on Age Premiums for services provided prior to April 1, 2019, that are processed and paid after April 1, 2019, will continue to be applied.

Remittance Advice Reporting

One or more of the following four accounting transaction messages will continue to report on the Remittance Advice (RA) report “Discount Accounting Transaction Summary Report” after April 1, 2019, to include the discount for claims and payments with service dates prior to April 1, 2019, which have been processed and paid after April 1, 2019.

  • PAYMENT REDUCTION-Automated PREMIUMS
  • PAYMENT REDUCTION-OPTED-IN
  • PAYMENT REDUCTION-OPTED-OUT
  • PAYMENT REDUCTION-PRIMARY CARE

In addition, a separate “Physician Payment Discount Report” will continue to be reported on the Remittance Advice to show the current month’s payment eligible for the payment reduction.  This will facilitate group and physician payment reconciliations.

Depending on the payment type and the period of reconciliation the adjustment and applicable discount(s) will continue to be reported after April 2019 to account for reconciliation for the period prior to April 2019.

Inquiries about the discount removal process for specific payments or primary care contracts as mentioned above can be directed to your usual program area contact.

For all other inquiries relative to the removal of discounts please contact the Claims Services Branch at 1-800-262-6524.

To view Portable Document Format PDF files, you will need to have Adobe Acrobat® Reader installed on your computer. You can download this free software from the Adobe website.

For More Information

Call ServiceOntario, Infoline at:
1-866-532-3161 (Toll-free)
In Toronto, (416) 314-5518
TTY 1-800-387-5559.
In Toronto, TTY (416)327-4282
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