Health law > FAQ: The OHIP Out-of-Country Program

  • November 10, 2008
  • David Baker
  • Comments Off on Health law > FAQ: The OHIP Out-of-Country Program

Sometimes the medical treatment you need is not available here in Ontario. Even when medical treatment is available here, wait lists and other delays can put your health or even life at serious risk.

To address these problems, OHIP provides an out-of-country program that, in certain circumstances, will pay the costs of your medical treatment outside Canada. Some private insurance plans also pay the cost of out-of-country treatment, but most only do so if the need for treatment arose outside of the country. You should check with your benefits-provider.

What Treatments Are Funded?

To qualify for funding from OHIP, the treatment you seek must be:

1. provided in a hospital or licensed facility where complex medical and complex surgical services are provided; OR be provided at a facility that is on OHIP’s approved list; AND

2. generally accepted as appropriate in Ontario for a person in the same medical circumstances (i.e. not experimental); AND

3. of a kind not performed in Ontario by an identical or equivalent procedure; OR currently unavailable in Ontario, and the delay that would result from waiting would result in death or serious, irreversible tissue damage.

How Do I Know Whether the Service Is Already Available Here?

Talk to your doctor or other medical professional about your options. For example, if the problem involves addictions, your doctor should consult Ontario’s Drug and Alcohol Registry of Treatment (DART) to determine whether treatment is available here before making an application to OHIP to have the service out-of-country. We can help you find other lists of treatment in Ontario to make sure that it isn’t available here.

How Do I Decide Where to Have the Treatment?

Discuss the options with your doctor, psychiatrist, therapist, or other professional. You can look at the list of out-of-country facilities or hospitals that OHIP has made agreements with. Otherwise, choose a facility that has a license and provides complex medical and complex surgical services.

When Should I Apply?

Generally speaking, you should apply and wait for a decision before the treatment starts. The Ministry of Health denies applications received after the treatment starts. There is an exception to this rule if you submit a late application because you were facing an immediate risk of death or medically significant irreversible tissue damage. If you have already received the treatment without making an application to OHIP, we can provide you with advice on whether this emergency circumstances exception applies to your case.

How Do I Make An Application?

The application form is called: “Prior Approval Application for Full Payment of Out-of-Country Health Services”. Click here for the online version.

The application must be signed by an Ontario doctor.  In some circumstances, you will need the support of an Ontario specialist. The application should be sent to the attention of the Out-of-Country Unit at the Ministry of Health in Kingston. The fax number is 1-866-221-3536. Urgent applications can be faxed to 613-536-3181.

Your doctor should also send to OHIP a letter explaining what kind of treatment you need, why you need it, and what he or she has done to find treatment in Ontario.

How Long Will I Have to Wait for A Decision?

Usually, you will receive a decision within a few weeks, but the application can be processed faster if you can show that the situation is urgent.

My Application Was Approved – What Happens next?

If the Ministry of Health approves the application, they will notify your doctor by fax. The letter your doctor receives explains exactly what services will be covered and under what terms.

Once the Ministry of Health approves an application, the Ministry of Health pays the treatment provider directly. Generally, drugs, equipment and education costs, and travel expenses are not covered. Uncovered costs may be eligible for the medical expense tax credit, under the Income Tax Act, or be covered under private health plans. The Ministry of Education may pay for a child’s education costs while treatment is being received out-of-country.

If you are approved for a specified treatment and you require an extension of the services, your doctor must write to the Ministry of Health and request the extension before your current treatment expires.

My Application was Rejected – What Happens Next?

If the Ministry of Health provides you with a letter rejecting your application, the letter should give the reasons for the decision. Sometimes, the Ministry of Health just needs more information from the doctor who signed the application, or from the medical centre providing the treatment. The letter you receive from the Ministry should give you an address for sending more medical evidence if you would like the Ministry to reconsider their decision.

The letter will also provide you with directions if you would like to appeal the Ministry’s decision to the Health Services Appeal and Review Board. Information about appealing to that Board is available at: http://www.hsarb.on.ca/english/default.htm. There is a 15-day time limit for appealing, so it is a good idea to seek legal advice as soon as possible if you are considering hiring a lawyer to help you with an appeal.

How Can Bakerlaw Help?

Bakerlaw regularly represents people in completing their applications to the Ministry of Health for out-of-country treatment. We have assisted many young people to secure funding for inpatient residential treatment for concurrent diagnoses (drug and alcohol addictions as well as mental health issues). We also represent adults with a variety of medical needs to receive the medical services they require in the US. We can help you to ensure that you have the best possible chance of success in getting funding from OHIP.

Physicians in Ontario are not paid by OHIP for completing these applications, and putting together a successful application can be time consuming. We assist in securing the medical evidence the Ministry will look for, and can assist busy physicians to ensure that they are providing the information required for a successful application.

If an application is denied, Bakerlaw can request that the Ministry of Health reconsider their decision, and can provide advice about whether to appeal the Ministry’s decision to the Health Services Appeal and Review Board. Bakerlaw represents clients in applications and appeals on a regular basis, and has assisted many clients in receiving funding for the treatment they need.

To discuss your application or appeal for out-of-country funding, please call us.

This brochure can be duplicated and/or included in publications by non-profit groups, with attribution. These answers to frequently asked questions are for information purposes only and should not be relied upon as legal advice.

Bakerlaw
4711 Yonge Street
Suite 509
Toronto ON
Phone: 416-533-0040
Fax: 416-533-0050
www.bakerlaw.ca

David Baker
(416) 533-0040; ext. 222
dbaker@bakerlaw.ca

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