Ontario Health Insurance Plan Plus or OHIP+ March 2019 Updates

The Ontario Government has announced that amendments to the OHIP+ plan are to take effect March 1, 2019.

What is OHIP+?

On January 1, 2018, OHIP+ began.  Eligible medications were to be covered by the Ontario Provincial Health Care program for children and youth aged 24 and under, who are covered by OHIP (the Ontario Health Insurance Plan). Enrollment in OHIP+ is automatic and coverage stops on the individual’s  25th birthday.

The new Ontario government announced, soon after they were elected in mid-2018, that they would be modifying the OHIP+ Plan to reduce the number of children and youth who would be eligible for the plan. Under a redesigned OHIP+, OHIP-insured children and youth 24 years of age and under who do not have private insurance would remain enrolled in the Ontario Drug Benefit program through the OHIP+ eligibility stream, and continue to receive benefits from the Ontario Drug Benefit program without co-payments or deductibles. For those children and youth who are covered by private insurance, drugs will be billed to those plans. Just as it was prior to the launch of OHIP+ private insurer will be first payor.

This change will be effective as of March 1, 2019.

How does OHIP+ Work?

If a drug is listed on the Ontario Drug Benefit (ODB) Formulary/Comparative Drug Index and a claimant, (without a private medical plan) is eligible for OHIP+ , then that drug would be dispensed  with no out of pocket expense at the pharmacy. All that is required, at the pharmacy, is a health card number and presents an eligible prescriptions.

Exceptional Access Program (EAP)

Fewer drugs are automatically eligible for coverage through the OHIP+ program than through private plans.  These drugs are managed through the Trillium Drug Program “Exceptional Access Program (EAP)”.  The EAP facilitates access to drugs not listed on the ODB formulary under specific clinical circumstances. Under this program, certain qualifying conditions must be satisfied before a drug is eligible and paid. Individuals eligible for OHIP+ or even those with a private plan who still find that they have significant out-of-pocket expenses, may submit a request for Trillium EAP funding.

The application and approval process through the EAP program can take anywhere between 3 days to 6 weeks, depending on the individual’s medical circumstances and the particular drug involved.  For individuals with private coverage, different insurance providers have different guidelines relating to the EAP process and ASSOCIUM can help determine how your provider integrates with the EAP and what options are available to cover high-cost medications.

How will the OHIP+ Changes Affect Me or My Employer?

As of March 1, 2019 private plans will, once again, be first payor for drug claims currently submitted to OHIP+. OHIP+ will no longer be a factor to private employee benefit plans. Though there was originally an expectation of reduced extended health care rates, there was not enough time for them to materialize. Going forward, we don’t anticipate much impact to rates once OHIP+ no longer applies to children and youth eligible to be covered by private plans.

Learn More about OHIP+

Contact ASSOCIUM Benefits to find out who may be eligible for alternate funding sources such as the EAP, what medications are covered and how to get it.