Ministry Programs

Ontario Health Insurance Plan (OHIP)

Protecting Access to Public Health Care

Through the Commitment to the Future of Medicare Act, 2004 (CFMA), the Ontario Government upholds requirements under the Canada Health Act for provinces and territories to prohibit extra-billing and user charges for insured health care services.

The CFMA ensures that patients with valid OHIP coverage are entitled to access insured health care services at no charge. The prohibitions under the CFMA apply to all OHIP-insured services provided to all insured Ontarians. The purpose of these prohibitions is to protect all patients and the publicly funded health care system and to ensure that Ontarians have reasonable access to insured health care services.

The CFMA prohibits:

• Extra-billing – Physicians and designated practitioners cannot charge more than the amount payable under OHIP for providing an insured service to an insured person.
• Charging patients for all or part of an insured service – No one can charge insured patients or their private insurers for a service that is insured under OHIP.
• Queue jumping – The CFMA prohibits anyone from accepting payment for giving patients preferred access to insured services. It also prohibits patients from paying an amount or some other benefit in order to receive preferred access to insured services.
• Using block or annual fees to restrict access to insured services  – The CFMA does not prohibit charging fees for uninsured services like preparation of sick notes or cosmetic surgery. However, the CFMA  prohibits a physician, practitioner, or hospital from refusing to provide access to insured services if a patient chooses not to pay a block or annual fee.

Ministry Action

The Ontario Ministry of Health (the ministry) reviews all possible CFMA violations that come to its attention.

If the ministry finds that a person has paid for an insured service or some component of an insured service in contravention of the CFMA, there is a mechanism under the CFMA that permits the ministry to ensure that the full amount of the payment is returned to that person.

Examples of Insured and Uninsured Services

Under the Health Insurance Act (HIA), OHIP provides payment for prescribed hospital services, medically necessary physician services, certain dental services that are required to be performed in a hospital and prescribed therapeutically necessary services provided by prescribed practitioners and certain health facilities.

The following table provides some examples of both insured and uninsured health care services:

Insured Services - Examples	Uninsured Services - Examples
Insured services are defined in the HIA, including: Medically necessary physician services Prescribed in-patient and out-patient hospital services Eye exams for specified patients in specified age groups Dental surgical services that require hospitalization Limited podiatry services	Uninsured services including: Services that are not medically necessary or are experimental Prescription drugs except when administered to hospital patients Eyeglasses, contact lenses, refractive eye surgery Dental services provided in non-hospital settings Cosmetic surgery that is not medically necessary People pay directly for uninsured services, or they may be covered by private insurance.

 

Examples of Patient Charges and CFMA Violations

Scenario	Can patients be charged?
You are a 70-year-old patient who has been charged by an optometrist for an eye exam. It has been more than 12 months since your last OHIP-insured eye exam.	Patients over the age of 65 are eligible to receive an OHIP-insured optometry eye exam every 12 months; therefore, you should not have been charged.
You are having cataract surgery and your physician has recommended that you have specific diagnostic tests prior to surgery. It is also suggested that you purchase a lens with additional features (e.g. ultraviolet filters) and, to correct astigmatism, that you have refractive surgery in association with your cataract surgery. You agree and pay for the diagnostic tests, refractive surgery and the full cost of the upgraded lens.	Medically necessary diagnostic tests (e.g. A-scan ultrasound biometry) required prior to cataract surgery are insured and you should not be charged for these services. Any non-medically necessary diagnostic tests and refractive surgeries are uninsured and optional and should not form a barrier to accessing insured services. It is your choice as to whether or not you want to pay for the uninsured services or have your third-party insurer pay for them. Likewise, you must be offered a standard medically necessary insured lens at no cost or a credit equal to the value of the medically necessary lens against the cost of the upgraded lens.
You have been told by your doctor's office that you must pay a mandatory fee in order to receive an insured assessment at their clinic.	Patients may be charged fees for uninsured physician services either individually, or in the form of a block or annual fee. However, patients cannot be required to pay any fees for insured physician services and cannot be required to pay for uninsured services in order to access insured physician services.
You receive a requisition for an MRI from your family physician. The wait time at your local hospital is 4 months long, so you contact a non-hospital clinic, who advises that they can provide an MRI to you within 1 week if you agree to pay a fee.	Under the CFMA, no person or entity (hospital, physician, clinic, etc.) can accept payment for giving a patient preferred access to an insured service, such as a medically necessary MRI. Also, patients who choose to pay a fee in order to access an insured service more quickly (i.e., queue-jumping) could also be in contravention of the CFMA.

Please Note:

• If you were charged for an insured service because of an issue with your health card (for example, because your health card had expired or you did not have it with you at the time of your visit to the doctor), please contact the health care provider for reimbursement once you can present your current valid health card. The health care provider must reimburse you in full for the cost of the service when you have provided proof of your OHIP eligibility for the service date.
• If you have trouble getting reimbursed by the health care provider once you have presented valid OHIP coverage, please contact the ministry’s Service Support Contact Centre by e-mail at sscontactcentre.moh@ontario.ca or by phone at 1-800-262-6524.
• If you have not been asked to pay any fee for insured services and are instead inquiring about whether or not a particular service is covered by OHIP, please contact the ministry’s Provider Services Branch by e-mail at providerservicesbranch@ontario.ca.
• Not all charges by health care providers are in violation of the CFMA. If you were charged and/or paid for a service that is not covered by OHIP, please note that there are no provisions under Ontario legislation that permit OHIP to pay for uninsured services. If you are unclear about whether the service is insured under OHIP, you may still request a review by the CFMA Program but please be advised that OHIP can not reimburse you the amount you paid for a service if it is not covered by OHIP.

If an individual believes that they may have been charged for an insured service or for access to an insured service, they should contact the ministry by e-mail at protectpublichealthcare@ontario.ca or by phone (toll-free) at 1-888-662-6613.