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To get public medical coverage under OHIP (the Ontario Health Insurance Plan), you must be a "resident" of Ontario. You must also be living in this province when you apply for coverage.

There is no "family coverage" under OHIP. A separate application must be made for everyone, including newborn babies. If you qualify, you receive a numbered Health Card with your photo on it. You must show this Card whenever you need medical care.

OHIP only pays for services that are medically necessary. It covers hospital care and the diagnosis and treatment of disease by physicians. It also covers the cost of a bed in a "standard" ward, but not in a private or semi-private room. It does not cover telephone consultations or medical reports for an employer or a legal proceeding. Doctors can bill you for these services, just as they can for missed appointments.

Who qualifies for OHIP?

To qualify for OHIP, you must be "ordinarily resident" in this province. That is, your principal home must be in Ontario. You must also be one of the following:

    • a Canadian citizen or landed immigrant,
    • a status Indian,
    • a Convention refugee,
    • an applicant for "landing" (permanent resident status) who has met the medical admissibility requirements,
    • someone on a work permit that is valid for at least six months, that names the Canadian employer, and that specifies the worker's occupation,
    • the worker's spouse or dependent child, provided that the Canadian employer states in writing that he or she intends to employ the worker for three years,
    • a visiting cleric (clergyman or clergywoman) with employment in Ontario for at least six months,
    • the cleric's spouse or dependent child, provided that the employer states in writing that he or she intends to employ the cleric for three years,
    • a foreign domestic worker who is in Ontario as a live-in caregiver,
    • someone on a Minister's Permit, provided that his or her Minister's Permit "case type" is number 86, 87, 88, or 89 (in other words, that he or she is an "early admission case," a Minister's Permit holder being processed for permanent residence), or
    • a child whose Minister's Pen-nit case type is number 80, if he or she is being adopted by someone covered by OHIP.

What about seasonal agricultural workers who come to Ontario from other countries? Can they get OHIP coverage?

It depends. OHIP has a special provision for people who come with employment authorizations issued by Canada Immigration under the Caribbean Commonwealth and Mexican Seasonal Agricultural Workers Programme. These people are eligible for OHIP right away and without being "ordinarily resident" in Ontario.

What about refugee claimants?

Medical care for refugee claimants is provided by the Interim Federal Health (IFH) program, not OHIP. If you make a refugee claim, Canada Immigration gives you documents showing you are entitled to IFH coverage. The IFH program provides essential health services for the prevention or treatment of serious medical and dental conditions, as well as contraception, prenatal, and obstetrical care. It does not cover all routine medical or dental services. For more information, contact Citizenship and Immigration Canada.

Is there a waiting period for OHIP?

Usually, yes. Most people have to wait three months after applying for OHIP. They are not insured during this period unless:

    • they are seasonal agricultural workers exempt from the waiting period,
    • they are children under 16 who are adopted by someone who is insured,
    • they are newborns born in Ontario to someone who is insured,
    • they can prove they have lived in Ontario at least three months before their application for OHIP,
    • they are found to be Convention refugees, or
    • they are among those with Minister's Permits who qualify for OHIP.

Under some circumstances, other people may also be exempt from the three month waiting period; for example, members of the Canadian Forces or Royal Canadian Mounted Police, diplo- mats, released prisoners, and people who move to a nursing home or home for the aged in Ontario from a province where they were covered by that province's health insurance plan.

Note: Anyone who moves to Ontario from a province where they were covered by that province's health insurance plan, is covered by that plan during their first three months in Ontario. To avoid a gap in coverage, however, you must apply for OHIP as soon as you arrive in Ontario.

What about newborn babies?

The rules that apply to older applicants apply to newborn babies. For example, a baby born in Ontario may qualify for OHIP as a Canadian citizen who lives in Ontario and intends to make his or her principal home in this province.

Babies born in Ontario are exempt from the three month waiting period if at least one of their parents is covered by OHIP.

What happens to my coverage if I leave Ontario for a while?

In the first 183 days (six months) after your OHIP application, you must spend at least 153 days in Ontario. To keep your coverage after that, you must spend at least 183 days in Ontario in any 12-month period.

How do apply for OHIP?

Application forms are available from your nearest Ministry of Health office, listed in the blue pages of your telephone book. Some doctors' offices and hospitals also have OHIP applications.

It's a good idea to submit an application even if you are told that you may not qualify for OHIP. Mail or deliver the completed form to the nearest Ministry of Health office. Include all the other documents requested on the application form.

If you give birth in a hospital, staff will give you an OHIP application form for your baby.

What if my application is turned down?

If OHIP turns you down, you should receive a written explanation for this decision. If you do not receive a written decision, contact the office where you applied and ask for it. Or ask a community legal clinic to help get the decision. You need a written decision before you can appeal the refusal.

Once you receive the written decision, you have 15 days to appeal to the provincial Health Services Appeal Board. You must appeal in writing, submitting your letter of appeal by mail or in person to the Health Services Appeal Board, with a copy to the General Manager of the Ontario Health Insurance Plan.

Addresses:

Health Services Appeal Board
151 Bloor Street West 9th Floor
Toronto, Ontario M5S 2T5
Tel.:
(416) 327-8512

General Manager OHIP
49 Place d'Armes 2nd Floor
Kingston, Ontario K7L 5J3

If 15 days have passed since you received the written decision, you can still try to appeal. Ask for an extension (more time) in your letter of appeal.

OHIP appeals are heard before a panel of the Health Services Appeal Board. The Board's decisions can be appealed to the Ontario Divisional Court.

If you are turned down for OHIP and want to appeal, it's a good idea to get help. Community legal clinics can provide free legal advice and, in some cases, legal representation at appeals.

What if I can't get OHIP but need medical care?

Many towns and cities in Ontario have community health centres where you may not need to show an OHIP card. Contact the centre nearest you and explain your situation. If you don't know where the centre is, ask for its address from your community information centre or public health office.

IMPORTANT TELEPHONE NUMBERS

Health Law:

Health Canada: 416-973-4389

College of Physicians & Surgeons: 416-967-2600, 1-800-268-7096

Ontario Ministry of Health - Information Centre: 416-327-4327, 1-800-268-1153

Ontario Health Insurance Plan (OHIP): 416-314-7444, 1-800-268-1154

Ontario Medical Association (OMA): 416-599-2580, 1-800-268-7215

http://www.ontario.ca/health-and-wellness/health-and-wellness

 
 

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