When I travel outside of Canada, will OHIP pay the same medical expenses that are covered in Ontario?

April 3, 2013 at 3:21 pm Leave a comment

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 certain 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 and ensure that the supplementary insurance you have purchased provides adequate coverage.

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, and only if certain conditions are satisfied (refer to section below “What is not covered by OHIP?”). Under Ontario’sHealth 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 include the conditions listed below that must be met :

  • the treatment must be medically necessary, and
  • the treatment must be performed at a licensed hospital or licensed health facility, and
  • the treatment must be rendered in relation to an illness, disease, condition or injury that :
    • is acute and unexpected, and
    • arose outside of Canadaand
    • requires immediate treatment.

These provisions 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 unexpected illness, disease, condition or injury 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.

What is not covered by OHIP?

OHIP does not cover:

  • treatment that is medically unnecessary
  • health services that are rendered at a facility that is not a licensed hospital or licensed health facility
  • treatment that is generally accepted by the medical profession in Ontario, as being experimental, or for research or for part of a study
  • treatment rendered for an illness, disease condition or injury that arose inside Canada
  • ambulance services or transportation costs
  • other services specifically set out in the regulations as uninsured or otherwise not listed as insured.

How much will OHIP pay?

  • The amount that OHIP pays is set by regulation. The amount paid for out-of-country health services isvery limited and usually will not be sufficient to cover the full cost of the services rendered. OHIP covers only very limited amounts for hospital, 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. You should also ensure that you understand the amount of protection provided by your supplementary health insurance provider because the amount of coverage may vary significantly from one insurance carrier to another. You should also check with your supplementary health insurance provider to determine if there are restrictions relating to pre-existing health conditions if these health conditions were not disclosed at the time your policy was purchased.
  • For physician services, OHIP will pay the actual cost billed by the out-of-country physician(s) or the cost of the same physician service(s) in Ontario, whichever is less. Physician services in Ontario are usually rendered at a significantly lower cost than those billed at out-of-country health facilities. Please note that out-of-country health facilities and physicians usually bill separately.
  • For outpatient emergency room services, OHIP will pay $50 Canadian (CDN) per day.
  • For inpatient services, OHIP will pay $200 CDN per day. If the services are inpatient services rendered in an operating room, coronary care unit, intensive care unit, neonatal or pediatric special care unit, thenOHIP will pay at the higher rate of $400 CDN per day for hospital services.

Should I obtain additional insurance coverage for my absence from Canada?

Yes. The ministry strongly recommends that 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. It is also recommended that you understand the terms and conditions of the additional insurance coverage you have purchased and the implications of any pre-existing health conditions on your insurance coverage. To obtain private insurance contact a private insurance company of your choice.

How long can I be absent from Canada and still maintain my OHIP coverage?

You may be temporarily outside of Canada for a total of 212 days in any 12 month period and still maintain your OHIP coverage as long as your primary place of residence is still in Ontario. However, the ministry does have extended absence provisions which are outlined below.

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