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Public Information Health Care Providers News Media Text Only Version |
This fact sheet provides basic information for health care providers and the public and should not be construed as legal advice. The authoritative source for OHIP eligibility is the Health Insurance Act and Reg. 552 thereunder. For the purpose of this fact sheet, OHIP defines the following terms : An “insured” person refers to an individual who is entitled to receive OHIP funded services under the Health Insurance Act and associated regulations. An “eligible” person refers to a person who is a resident of Ontario who has applied for and qualified for Ontario health insurance under the terms of the Health Insurance Act and associated regulations. “Coverage” is defined as the insurance provided by the Ontario Health Insurance Plan (OHIP) to eligible residents of Ontario. It means that while you are away and upon your return to Canada, there will be no interruption to your eligibility status with OHIP. When I travel outside of Canada will OHIP pay the same medical expenses that are covered in Ontario?
No. If you are a resident of Ontario and you are insured under OHIP, you are entitled to very limited funding for a limited range of medical services when you are travelling outside of Canada. For this reason, you are strongly advised to purchase additional health insurance every time you leave Canada. What does OHIP cover while I’m out of the country?
OHIP will pay very limited amounts for physician services and hospital/health facility services if certain conditions are satisfied (refer to section below “What is not covered by OHIP?). Under Ontario’s Health Insurance Act and regulations, physician services are subject to different conditions than hospital services. OHIP will pay only for insured, emergency out-of-country health services that are rendered to an insured person. To qualify as an ‘emergency’ there are a number of criteria that must be satisfied. These criteria are set by regulation and all conditions listed below must be met:
These conditions are intended and designed to provide a very limited amount of funding for the medical treatment of insured residents of Ontario if they incur an injury or develop a disease while they are outside of Canada. If the illness, disease, condition or injury arises before you leave Canada, or if it is not acute or unexpected, no payment can be made. OHIP does not cover :
How much will OHIP pay?
The amount that OHIP pays is set by regulation. The amount paid for out-of-country health services is very limited and usually will not be sufficient to cover the full cost of the services rendered. OHIP covers only very limited amounts for both health facility and physician services. You are strongly advised to purchase additional health insurance every time you leave Canada to cover any expenses in excess of the limited funding provided by OHIP. OHIP will not pay more than the service would have cost in Ontario.
The “per day” rates listed above cover all hospital inpatient services including, but not limited to, accommodation, meals, prescription drugs, surgically implanted devices and nursing services. Note : OHIP does not pay for ambulance services, transportation costs, or out-of-hospital food/accommodation/drugs or prescriptions. Should I obtain additional insurance coverage for my absence from Canada?
Yes. The ministry strongly recommends you do, whether you are absent from Canada for a few minutes or for an extended time. OHIP does not insure or pay for all out-of-country medical services. Also, the amount of funding provided by OHIP will not usually cover the full cost of any health services that you do obtain outside of Canada. You should therefore, obtain supplementary health insurance from a private insurance company to provide you with additional coverage during your absence. To obtain private insurance contact a private insurance company or call the Canadian Life and Health Insurance Association Inc. at 1 800 268-8099; in Toronto call (416) 777-2344. How long can I be absent from Canada and still maintain my OHIP?
You may be outside of Canada for a period of 212 days in any 12 month period and still maintain your OHIP coverage. How long do I have to stay in Ontario immediately after I apply for coverage?
If you have moved to Ontario from outside Canada, or if you have moved from another Canadian province or territory and were not insured by that province or territory’s health plan, you must be present for 153 days in the first 183 days immediately following the date you establish residency in Ontario (i.e., you cannot be absent for more than 30 days during the first 6 months of residency in Ontario). What if I’m going to be absent from Canada for a long period of time?
If you are out of the country for more than 212 days in any 12-month period, you may still be eligible for continuous Ontario Health Insurance Plan eligibility if you are away for one of the following reasons :
To be eligible for continuous OHIP eligibility during one of these extended absences you must first have been physically present in Ontario for at least 153 days in the 12-month period, for 2 consecutive years before the absence (refer to section above “What does it mean to be “eligible for continuous OHIP eligibility?). How do I apply for an extended absence?
To confirm your continuous OHIP eligibility during your longer absence, write or visit your local OHIP office before you leave Ontario to apply for an absence. You may need to show a document explaining the reason for your absence as required by the ministry; for example, a letter from a school, employer or a sponsoring religious organization. You should telephone the ministry prior to your visit to confirm the require documentation. How long will OHIP provide me with continuous eligibility during an extended absence?
Lengths of extended absences vary depending on the reason for the absence.
Extended absences are processed for minimum increments of one year. If you are away for more than 212 days in any 12-month period but do not use the full year provided for your extended absence, the ministry will not add the remaining time to another absence. If, however, you are away from Ontario on an approved absence, you may be eligible to remain away for a longer period and still maintain continuous OHIP eligibility. For more information, contact your local OHIP office. Are longer absences permitted for my family?
In most cases, your spouse or same-sex partner and dependent children under nineteen years of age are permitted to be out-of-Ontario to accompany you on your extended absence for study, work or missionary work, and still maintain OHIP coverage. They must, however, notify the ministry separately if their absence is for a vacation or any other reason. If I must be away frequently because of my job, am I eligible for OHIP coverage?
If your job requires you to leave Ontario frequently and you are unable to be present for 153 days in any 12-month period, you may still be eligible for OHIP coverage as a mobile worker. To maintain your OHIP coverage, you should :
New or returning residents to Ontario who qualify as a mobile worker are exempt from having to meet the 153- day in the first 183-day physical presence requirement immediately after establishing residency in Ontario. How do I make a claim to OHIP?
If you receive insured emergency out-of-country health services that meet the criteria established above (refer to section “When I travel outside of Canada will OHIP pay the same medical expenses that are covered in Ontario?”) you should:
Note: Before submitting original documents, please make photocopies for your records. |
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Call the ministry INFOline at 1-800-664-8988 (Toll-free in Ontario only) TTY 1-800-387-5559 Hours of operation : 8:30am - 5:00pm |
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