On January 2, 2019, the Ontario Ministry of Health and Long Term Care issued a notice providing information regarding proposed changes to Ontario Regulation 201/96 made under the Ontario Drug Benefit Act that would, if approved, come into force at a future date. The government’s purpose for the proposed changes is to fix OHIP+ by focusing benefits on those who need them the most. The proposed changes are scheduled to be implemented in March 2019, however, a specific date has not yet been finalized. The proposed changes are detailed below.
Children and youth who do not have existing prescription drug benefits covered by private plans will continue to receive coverage through OHIP+. For those children and youth who are covered by private insurance, they will bill those plans.
The proposed regulatory amendments would change the current Ontario Drug Benefit program coverage for children and youth aged 24 years and under who are currently covered under OHIP+ as follows:
- 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.
- Children and youth (excluding social assistance recipients, recipients of home care, and residents of homes for special care or a community home for opportunity) with private insurance:
- Would access prescribed medicines as they did prior to the launch of OHIP+ through their private insurer.
- Individuals or families who have significant out-of-pocket costs, despite having private insurance coverage, could apply for additional financial support through the Trillium Drug Program.
- The Trillium Drug Program is an application-based, income-tested program that is available to all OHIP-insured Ontarians, which helps with prescription drug costs for those with high drug costs compared to their household income. Households enrolled in the Trillium Drug Program would have an annual deductible (divided into quarters) based on their household income, which must be paid before benefits would be funded through the Ontario Drug Benefit program.
- Where the out-of-pocket costs for these children/youth do not reach the Trillium Drug Program deductibles, no public coverage would be provided (unless the child/youth becomes eligible through another eligibility stream, such as social assistance, home care recipient, etc.).
- Where the out-of-pocket costs for these children/youth meet the Trillium Drug Program deductibles, public coverage would be provided under existing program requirements.
Children and youth who are eligible for the Ontario Drug Benefit Program through social assistance, their receipt of home care services, or their residence in a home for special care or community home for opportunity would have no copayments or deductibles.
Private insurance is defined as any type of private plan, program or account which could contribute to the cost of any drug product, regardless of whether:
- the private insurance plan covers the particular drug for which coverage is sought,
- the child or youth or another person captured under the private insurance plan is required to pay a co-payment, deductible, or premium, or,
- the child or youth has reached their annual maximum under the private insurance plan and no further coverage is available.
A summary and draft of the proposed amendments to the regulations are available on the Regulatory Registry website.
This newsletter has been written in general terms to provide broad guidance only. It should not be relied upon to cover specific situations and you should not act upon the information contained herein without obtaining specific professional advice. Please contact our office to discuss this information in the context of your specific circumstances. We accept no responsibility for any loss or damage resulting from your reliance on the information in this newsletter.