Recently, the Government of Ontario and insurer Industrial Alliance (IA) prepared some helpful information related to the upcoming changes to OHIP+. Our team assembled those details below to help our clients and plan administrators manage the transition.
APRIL 1, 2019 OHIP+ WILL NO LONGER COVER INDIVIDUALS 24 YEARS OLD AND UNDER WITH DRUG COVERAGE THROUGH A PRIVATE INSURANCE PLAN.
This is a major change to OHIP+ which impacts all youth aged 24 years and under covered by a private group insurance plan. Effective April 1, 2019 prescription drug claims must be submitted to a private group plan or to a health spending account (HSA).
What is considered a private group insurance plan?
Youth aged 24 years and under are considered covered by a private group insurance plan if they have drug insurance benefits or if they have access to a health spending account (HSA).
What if a plan member (parent) has a dependent under the age of 24 and they are not covered by the plan member’s group insurance plan?
If their dependent does not have access to drug insurance coverage, those youth aged 24 and under can benefit from OHIP+.
How does a plan member (parent) get access to OHIP+ for a child 24 years or under and needs a covered medication?
- Visit the child’s doctor or nurse practitioner and get their prescription.
- Take their health card OR health card number to any pharmacy in Ontario – they don’t need a separate or special card.
- The pharmacy will fill their prescription at no charge – they don’t pay a dispensing fee, deductible or co-payment.
Can plan members submit a claim to OHIP+ if their drug claim exceeds the benefit limit of their group plan?
No. If a drug cost exceeds the group plan annual limit, the plan member must enroll in the Trillium Drug Program, which could provide them with financial support.
Can plan members submit a claim to OHIP+ for a drug not covered by their group plan?
No. A plan member must enroll in the Trillium Drug Program which may reimburse them for these drugs.
What happens if a plan member’s pharmacist accidentally submits a claim and OHIP+ pays?
The pharmacist will be able to correct this situation by reversing the claim and submitting it to the private group insurance plan.
Will plan members be reimbursed at the same rate as OHIP+ when submitting their claim to the private group plan effective April 1, 2019?
No, not necessarily. Claims made to a private group plan will be reimbursed based on the terms of your private group insurance contract.
For more information visit: https://www.ontario.ca/page/learn-about-ohip-plus