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Ontario Health Insurance Plan

Regulation Amendment: Questions and Answers

What changes have been made to the Out of Country (OOC) Program?

Several changes were made to Regulation 552 under the Health Insurance Act for the purpose of clarifying the conditions under which OHIP will provide public funding of out-of-country (OOC) health services for medical conditions arising inside Ontario. These changes will be introduced in two phases. Changes effective April 1, 2011 will:

Changes effective October 1, 2011 will:

When do these regulation changes come into effect?

These amendments will be introduced in two phases. Some changes will become effective April 1, 2011. Amendments regarding OOC drug therapy will be introduced on October 1, 2011.

How can I obtain a copy of the revised regulation?

The revised regulation should be available through the e-laws website within 2 days of coming into effect. A link to this new regulation can be found on the ministry’s OOC website:

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Why were these changes introduced now?

The OOC provisions of the Regulation have been amended to align the funding of OOC health services with the funding of health services inside Ontario. This is part of a broader initiative to update and improve the OOC Prior Approval Program which includes significant measures to create capacity inside Ontario for services that are routinely funded OOC.

How much will these regulation changes cost taxpayers?

The changes are expected to save taxpayers millions of dollars each year, mostly through the elimination of funding for OOC services that can be provided in Ontario in a timely manner and through the alignment of funding of OOC coverage with coverage inside Ontario.

Will these regulation changes affect Ontario residents who are seeking treatment through the OOC Program?

The regulation changes will have only a minimal impact on Ontarians. The OOC Prior Approval Program will continue to provide funding for OOC health services that are medically necessary, not experimental, and generally accepted as appropriate by the medical profession in Ontario, when those services are either not performed in Ontario or not available in a timely manner.

According to the amendments, patients on whose behalf applications for funding of OOC health services were submitted prior to April 1, 2011 (or October 1, 2011 in the case of drug therapy) will not be affected by these changes. Those applications will be reviewed according to the old provisions.

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What happens if the wait time to see an Ontario specialist is too long?

Over half of Ontario’s approximately 25,000 physicians are specialists; however, in the event that a General Practitioner determines that the wait time to see a specialist in Ontario would result in medically unacceptable delay, that General Practitioner may submit an application for prior approval of funding of an OOC specialist consult. Depending on the results of the consult, the General Practitioner may choose to submit an application for prior approval of funding for OOC treatment. The ministry will then work with the General Practitioner to obtain the required specialist endorsement.

I have a rare medical condition. Will I still be able to access OOC medical expertise?

The provision of funding for OOC services that are not performed in Ontario remains the primary purpose of the OOC Prior Approval Program. The regulatory amendments do not change this.

What if the Ontario physician does not have as much experience as the OOC physician?

When there is an available Ontario physician who is qualified to provide the service, then the service would be provided in Ontario. Ontario physicians are regulated by the College of Physicians and Surgeons of Ontario, which requires that Ontario physicians practice within the scope of their training and experience.

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