Ontario Health Insurance Plan

INFOBulletin

Temporary COVID-19 Premiums and Management Fees

Temporary Payments for Selected Premiums and Management Fees During the COVID-19 outbreak


To: All Physicians
Category: Physician Services
Written by: Health Services Branch, Ontario Health Insurance Plan Division
Date issued: April 9, 2021
Bulletin Number: 210402


Table of Contents

Background
K083 Premiums
K082 Focused Practice Psychotherapy Premium
Family Health Group (FHG) Physicians-10% Premium
Management Fees for Services by Telephone or Video
Monthly Management of a Nursing Home or Home for the Aged Patient by Telephone or Video
Point of Care Drug Testing During COVID-19
After Hours Procedure Premiums During COVID-19
This bulletin is a general summary
The Schedule of Benefits for Physician Services
Keywords/Tags
Contact Information

Background

To ensure patients continue to access the heath care they need through the pandemic and the roll-out of the COVID-19 vaccine in Ontario, Schedule of Benefit for Physician Services (Schedule) amendments have been approved. These changes reflect an agreement between the Ministry of Health (ministry) and the Ontario Medical Association (OMA) to extend existing temporary payments for selected premiums and management fees under the Ontario Health Insurance Plan (OHIP) to September 30, 2021 and November 28, 2021, as outlined below. Please refer to INFOBulletins 4764 and 201110 for more details.

The amendments also reflect the ministry and OMA agreement to temporarily extend the focused practice psychotherapy premium to K082 psychotherapy services for the period of March 14, 2021 to September 30, 2021, as outlined below.

Further to INFOBulletin 210304, titled ‘COVID-19 Temporary Physician Funding, this INFOBulletin provides additional information on these temporary funding initiatives.

K083 Premiums

Effective March 14, 2021 the Schedule is being amended to permit payment of the temporary K083 Premiums listed in the K083 Premiums Table below, to specialists when providing K083 services, until September 30, 2021.

K083 Premiums Table

Applicable Premium Descriptor Premium

Age-Based Fee Premiums

Less than 30 days of age

30%

Age-Based Fee Premiums

At least 30 days but less than one year of age

25%

Age-Based Fee Premiums

At least one year but less than two years of age

20%

Age-Based Fee Premiums

At least two years but less than five years of age

15%

Age-Based Fee Premiums

At least five years but less than 16 years of age

10%

Internal Medicine Office Assessment Premium

 

12%

E078

Chronic Disease Assessment Premium

50%

E060

Post renal transplant assessment premium

25%

K630

Psychiatric consultation extension

$113.70

K187

Acute post-discharge community psychiatric care

15%

K188

High risk community psychiatric care

15%

K189

Urgent community psychiatric follow-up

$216.30

The temporary K083 Premiums are payable when all the conditions in the Schedule that apply to the premiums for services rendered in-person are met, other than for a direct physical encounter with the patient.

For the purpose of K083 services that include K083 Premiums payments, the total increments eligible for payment is equal to the fee listed in the Schedule for the appropriate service, plus the value of the applicable K083 Premium(s), rounded to the nearest $5, divided by 5. Please see INFOBulletin 4764 for examples.

K082 Focused Practice Psychotherapy Premium

Effective March 14, 2021 the Schedule is being amended to temporarily permit payment of the focused practice psychotherapy premium with K082 psychotherapy services for eligible physicians.

K082 for psychotherapy will be included as a service for which the amount payable to an eligible physician shall be automatically increased by 17% for the focused practice psychotherapy premium. K082 for psychiatric or primary mental health care, counselling, or interviews are not included as services to which this premium applies.

For the purposes of the K082 Focused Practice Psychotherapy Premium, the ministry will be reviewing diagnostic codes that accompany the claim for payment of the 17% premium. K082 claims submitted with diagnostic codes under the categories of mental health disorders in the ranges from 290 to 319 and from 897 to 909 will be considered a service for psychotherapy, and not K082 claims submitted with other diagnostic codes outside this specified range. Please submit all claims for virtual care psychotherapy services using the 290 to 319 or 897 to 909 ranges of diagnostic codes.

While the above noted diagnostic codes will be used for the purpose of identifying psychotherapy services for payment of the K082 Focused Practice Psychotherapy Premium, they are not inclusive of all psychotherapy services.

While the K082 Focused Practice Psychotherapy Premium is effective March 14, 2021, premium payments for claims with service dates for the period of March 14, 2021 to September 30, 2021 will not be made until Spring 2022 to accommodate the six month claims submission window. More information will be provided in a future INFOBulletin.

Family Health Group (FHG) Physicians-10% Premium

Effective March 14, 2021 payment of the temporary FHG 10% premium with virtual care K-code services (K080, K081, and K082) is being extended until September 30, 2021. This FHG premium will be paid automatically to FHG physicians rendering these virtual care K-code services to enrolled/assigned patients.

Management Fees for Services by Telephone or Video

Effective March 14, 2021 the Schedule is being amended to temporarily permit K080, K081, K082 and K083 to be included as a consultation or assessment for the purposes of meeting the requirements for payment of the applicable management fee(s) listed in the Management Fees for Services by Telephone or Video Table below, until September 30, 2021.

Management Fees for Services by Telephone or Video Table

Fee Code Descriptor

K045

Endocrinology & Metab/Internal Med-Diabetes management by a specialist-annual

K046

Endocrinology & Metab/Internal Med-Diabetes team management-annual

K119

Paediatrics-Paediatric developmental assessment incentive-annual

K481

Rheumatology-Rheumatoid arthritis management by a specialist-annual

Q040

GP/FP-Diabetes management incentive-annual

K682

Opioid Agonist Maintenance Program monthly management fee-intensive, per month

K683

Opioid Agonist Maintenance Program monthly management fee-maintenance, per month

K684

Opioid Agonist Maintenance Program-team premium, per month, to K682 or K683 add

Despite the above, where the Schedule requires that specific element(s) of physical examination(s) must be completed for the year in order for the management fee to be payable, an in-person physical examination(s) must take place for physicians to qualify for payment of the applicable management fee. Please refer to INFOBulletins 4764 and 201101 for more details and claims submission information.

Monthly Management of a Nursing Home or Home for the Aged Patient by Telephone or Video

Effective March 14, 2021 the Schedule is being amended to temporarily permit payment of the Monthly Management of a Nursing Home or Home for the Aged Patient (W010) where patient care is delivered by telephone or video, until September 30, 2021.

As of March 14, 2021, K080, K081, K082 and K083 will be included as services described in the Definition/Required Elements of W010, despite any requirement in the Schedule for a direct physical encounter with the patient.

Payment for W010 is for management of the patient for the entire month during which all of the services listed as components of the W010 service are rendered, regardless of when the claim for W010 is submitted. When claiming W010, do not also submit claims for K080, K081, K082 or K083 for the same month for the same patient as they are not separately payable.

Point of Care Drug Testing During COVID-19

Effective retroactive to March 14, 2020 and until March 13, 2021 the ministry and the OMA have agreed that payments equivalent to Schedule payments will temporarily be made for four point of care drug testing services (described in the Schedule by G040, G041, G042 and G043) when consultations and assessments using virtual care K-code services (K080, K081, K082 and K083) are provided as an alternative to in person consultations and assessments required for the accumulations or limits that apply in the Schedule to receive payment for insured point of care drug testing. Equivalent payment amounts will be the same as the Schedule value of these four applicable point of care drug testing fees.

By claiming and accepting these temporary equivalent payments for point of care drug testing, physicians will be deemed to agree to the following terms and conditions:

  • All other payment requirements in the Schedule that are applicable to the eligible point of care drug testing must also be met for these equivalent temporary point of care drug testing codes to be payable.
  • The same claims submission requirements for insured services in Regulation 552 under the Health Insurance Act must also be met when submitting claims for the equivalent temporary point of care drug testing payments described above.

Effective March 14, 2021 the Schedule is being amended to temporarily permit K080, K081, K082 and K083 to be included as a consultation or assessment for the purposes of meeting the requirements for payment of G040, G041, G042 and G043, despite any requirement in the Schedule for a direct physical encounter with the patient.

While all of the payments for the above listed point of care drug testing fees are effective retroactive to March 14, 2020, system changes required in order to process these payments will be implemented for April 1, 2021.

Equivalent temporary payments that are claimed using fee codes G040A, G041A, G042A and G043A will be exempt from stale date claims policy and processing will be permitted to be submitted until June 30, 2021.

After Hours Procedure Premiums During COVID-19

As per INFOBulletin 201110, the ministry and OMA previously agreed to revised payment criteria for physicians to receive a premium when performing after hours surgical or other procedures as listed in General Preamble in the Schedule, effective November 28, 2020 until March 31, 2021. The ministry and OMA have now agreed to continue this until November 28, 2021.

Physicians (other than Emergency Department Physicians) continue to be eligible for payment of the After Hours Procedure Premiums (E409 and E410) when the service provided is an elective in-hospital, Independent Health Facility (IHF), or non-hospital based surgical or other procedure, and is commenced after hours, on a weekend/holiday, or at night. Please refer to INFOBulletin 201110 for more details.

This bulletin is a general summary

This bulletin is a general summary provided for information purposes only. Physicians are directed to review the Health Insurance Act, Regulation 552, and the schedules under that regulation, for the complete text of the provisions. In the event of a conflict or inconsistency between this bulletin and the applicable legislation and/or regulations, the legislation and/or regulations prevail.

The Schedule of Benefits for Physician Services

You can access current legislation and regulation at ontario.ca/laws. The latest version of the Schedule of Benefits for Physician Services is available on the Ministry of Health website. Hard copies of the Schedule of Benefits for Physician Services will not be distributed. If you would like to order a paper copy or compact disk (CD) of the Schedule for a fee, please visit Publications Ontario. Physicians without access to the Internet can contact ServiceOntario at 1-800-668-9938.

Keywords/Tags

COVID-19; Premiums; Management Fees; K083; K082; Focused Practice Psychotherapy Premium; FHG Premium; W010; Point of Care Drug Testing; G040; G041; G042; G043; After Hours Procedure Premium; E409; E410

Contact Information

Do you have questions about this INFOBulletin? Email the Service Support Contact Centre or call 1-800-262-6524.

Find INFOBulletins online on the Ministry of Health website.

 

For More Information

Call ServiceOntario, Infoline at:
1–866–532–3161 (Toll–free)
In Toronto, (416) 314–5518
TTY 1–800–387–5559.
In Toronto, TTY (416)327–4282
Hours of operation: Monday to Friday, 8:30am – 5:00pm

 
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