Ontario Health Insurance Plan

Resources for Physicians

This document is technical in nature and is available in English only due to its limited targeted audience.
This publication has been exempted from translation under the French Language Services Act.

 

Ce document est de nature technique et est disponible en anglais uniquement en raison de son public cible limité. Ce document a été exempté de la traduction en vertu de la Loi sur les services en français.

Registration for Ontario Health Insurance Coverage


OHIP Registration Overview

Typically, to obtain Ontario health insurance coverage initially or to reactivate OHIP coverage and be issued an Ontario health card, eligible residents over the age of 16 must apply in person at a ServiceOntario centre.

To receive Ontario health insurance coverage, each eligible resident must apply and substantiate basic personal information by providing documentary proof of his or her Canadian citizenship/immigration status, residency within Ontario and identity.

Information on each registered person is collected by means of a standard registration form issued by the ministry and stored as electronic data on the Registered Persons Data Base (RPDB). Every eligible person who applies for Ontario health insurance coverage is assigned a permanent and unique health number.

People 16 years of age and older must register in person to provide their signature and to have their photo taken. There may be exemptions from photo and/or signature requirements for medical or other reasons.

Upon approval for Ontario health insurance coverage, client registration and identification information is entered onto the ministry’s RPDB. The insured person is issued a plastic health card bearing his or her photo, signature, name, health number and version code, date of birth, and validity period. In most cases, when a change in information is made or the card is reported lost, stolen, damaged or not received, a replacement card will be issued with the same health number and a new version code.

People with a valid health card and eligibility can obtain insured medical and hospital services, prescription drugs (for a limited population group) and prove entitlement to various other provincially funded health services and benefits.

The RPDB is used in various ministry-processing systems to verify eligibility for services. A significant use of the data is in the fee-for-service medical claims system where claims can be paid to the provider if the patient has eligibility and a valid health card.

Back to top 


Eligibility Overview

Every applicant who is determined to be eligible for Ontario health insurance coverage becomes an insured person and is issued a health card. To receive insured services, the insured person must present his or her health card upon the request of the health care provider.

All personal information, including personal health information stored by the ministry, is protected by the Personal Health Information Protection Act (PHIPA). Every registered person should ensure the information on his or her registration record in the ministry’s RPDB is up-to-date. Maintaining the accuracy of the information in the RPDB is essential for ensuring ongoing eligibility for Ontario health insurance coverage.

Eligibility policies are based on Regulation 552 of the Health Insurance Act (HIA).

To be eligible for Ontario health insurance coverage, generally speaking a person must:

  • have Canadian Citizenship or other immigration status as listed in the regulation;
  • make his/her primary place of residence in Ontario; and
  • be physically present in Ontario for 153 days in any given 12-month period.

In addition, most new and returning applicants for OHIP coverage must also be physically present in Ontario for at least 153 of the first 183 days after establishing residence in the province (exceptions are noted in Regulation 552).

Most eligible new or returning residents are subject to a 3-month waiting period prior to the effective date of coverage.

Visitors to the province, those who have their primary place of residence outside Ontario, and tourists are not eligible for Ontario health insurance coverage.

An OHIP-eligible resident can be away from Ontario for up to 7 months in any 12-month period and still maintain their OHIP coverage.

In addition, Regulation 552 of the HIA includes provisions for maintaining OHIP coverage during specific types of longer temporary absences out of the country provided certain requirements are met.

It is the responsibility of every insured person to report, within 30 days of its occurrence, a change in the information that was used to establish his or her entitlement to be or continue to be an insured person.

Regulation 552 also notes that a person may be asked to submit any information, evidence or documents necessary to determine a person’s entitlement for OHIP, whether the person is applying to be an insured person for the first time or seeking to re-establish coverage.

Participation in the Ontario health plan is voluntary; however, coverage of residents with a private health insurance policy for services that are insured and rendered in Ontario is prohibited.

Back to top 


Health Cards

Each eligible resident in the province of Ontario may apply to be an insured person to receive provincially funded insured health services covered by the Ontario Health Insurance Plan (OHIP). A health card is provided to the insured person to present to the health services provider at each visit for an insured health service.

There are two types of Ontario health cards in circulation - the photo health card and the red and white health card.

Health services providers should continue to validate all health cards at the time of service using existing validation processes.

Both the photo and the red and white health cards remain acceptable as proof of entitlement to medically necessary insured health services providing the card is valid and belongs to the person presenting the card. All health cards contain a magnetic stripe that contains the unique 10-digit lifetime identification number, known as a health number which is assigned to all eligible Ontario residents.

Variations of each of these health cards are detailed below.

Back to top 


Health Cards for Newborns

The registration of newborns through hospitals is usually completed using the Ontario Health Coverage Infant Registration form. The registration form, completed by the parent, is forwarded by the birthing hospital to ServiceOntario for processing.

Until the child’s health card is mailed to the parents, the parent will have a record of the child’s health number preprinted on the registration form’s tear-off strip.

Back to top 


Photo Health Card

The photo health card, introduced in February 1995, represented a government action to protect the integrity of the health care system and to preserve it for the future. The photo health card contains several security features as illustrated in the examples that follow.

Since 1995, additional security features have been added to the photo health card to make it more tamperproof and counterfeit resistant.

The photo health card is a green plastic card with the front of the card depicting a trillium and bearing the insured person’s name, 10-digit personal health number and version code, date of birth, sex (on cards issued prior to June 2016 only), cards issue and expiry date, the person’s photo and signature (unless a photo and signature exemption has been granted or the person is under 16 years of age).

There are multiple variations of the photo health cards in circulation.

Back to top 


Black and White Photo Health Card (no Sex Designation) - Description

  • This is the only photo health card that is currently being produced.
  • It is considered acceptable as proof of OHIP coverage if it was issued after June 13, 2016 (see INFOBulletin 4671).
  • The following changes were made to this version of the card:
    • The front of the health card will no longer display the individual’s sex designation; however it is available for retrieval from the magnetic stripe of the health card (the information is still required to be entered on the OHIP database).
    • No changes have been made to the back of the black and white photo health card.

Black and White Photo Health Card

Black and White Photo Health Card (no Sex Designation) - Front

  1. Trillium Image
    • Optical variable ink added in top right corner on the card front.
    • New trillium image changes colour from magenta to gold when card is tilted.
  2. Primary Photo
    • Primary photo of the card holder is now black and white image.
    • Holographic image is removed.
  3. Secondary Photo
    • Greyscale of primary photo.
    • Secondary signature.
    • Redundant data.
  4. Security Background
  5. Variable Microprint
  6. Tactile Features
    • Apparent to touch and feel without any special tool
    • Ontario trillium logo unique to Ministry of Health and Long-Term Care
    • Primary signature, health card number

Black and White Photo Health Card (no Sex Designation) - Back

  1. Bearer Related Data
    • Donor information Laser engraved into card material
  2. 2-D Barcode
    • Encoding specific amount of data Machine readable
  3. Magnetic Stripe
  4. Stock Control Number
  5. Variable Microprint

Back to top 


Black and White Photo Health Card - Description

  • It is considered acceptable as proof of OHIP coverage if it was issued between January 8, 2014 to June 13, 2016 (see INFOBulletin 4621). 
  • The following changes were made to this version of the card: 
    • The primary photo of the card holder is a black and white image. 
    • The holographic images previously seen covering the primary photo have been removed. 
    • Optical variable ink was added in the top right corner on the card front. The trillium image changes colour from magenta to gold when the card is tilted. 
    • The old provincial logo in the bottom right corner on the card front was replaced with a tactile image of the new provincial stylized logo. 
    • Both the English and French text on the back of the card was updated as to reflect how to request a change of address on the Ontario health card.

Black and White Photo Health Card

Black and White Photo Health Card (no Sex Designation) - Front

  1. Trillium Image
    • Optical variable ink added in top right corner on the card front.
    • New trillium image changes colour from magenta to gold when card is tilted.
  2. Primary Photo
    • Primary photo of the card holder is now black and white image.
    • Holographic image is removed.
  3. Secondary Photo
    • Greyscale of primary photo.
    • Secondary signature.
    • Redundant data.
  4. Security Background
  5. Variable Microprint
  6. Tactile Features
    • Apparent to touch and feel without any special tool
    • Ontario trillium logo unique to Ministry of Health and Long-Term Care
    • Primary signature, health card number

Black and White Photo Health Card (no Sex Designation) - Back

  1. Bearer Related Data
    • Donor information Laser engraved into card material
  2. 2-D Barcode
    • Encoding specific amount of data Machine readable
  3. Magnetic Stripe
  4. Stock Control Number
  5. Variable Microprint

Back to top 


Red and White Health Card - Description

In 1990, the ministry introduced individual health numbers and issued new red and white health cards to all eligible residents of Ontario. Those over the age of 65 were issued a red and white health card displaying “65” on the face of the card.

There are four versions of the plastic red and white health card currently in circulation.

All of the following red and white health card types are acceptable if they are valid and belong to the person presenting them. Each displays the 10-digit personal health number, the insured person’s name and version code if applicable.

As a reminder, all health cards should be validated at point of service to ensure they are valid.

Description of Red and White Health Card

  1. Health number
  2. Name
  3. OHIP number
  4. Expiry date of coverage (month/year) - not displayed on most red and white cards
  5. Version code - on replacement cards only
  6. Health 65 Indicator - signifies eligibility for Ontario Drug Benefit
  7. Date of Birth
  8. Sex

Back to top 


Health Card Validation

Health Card Validation (HCV) allows a health care provider to access the information in the ministry’s Registered Person Database (RPDB) to determine if a patient’s health number and version code are valid when presented at the point of service.

Back to top 


Why Validate?

HCV provides decision-making information at the time of service and allow a health care provider or organization to:

  • Verify patient data;
  • Reduce eligibility claim rejects by ensuring a client is eligible for service prior to service delivery;
  • Reduce version code claim rejects associated with incorrect version codes;
  • Receive the most recent oculo-visual assessment, bone mineral density measurement or sleep study date of service (currently only available by the Interactive Voice Response method); and
  • Reduce health care fraud by eliminating service to ineligible clients and by visually confirming HCV response information with client at the point of service; for example, gender, date of birth.

Back to top 


Types of Health Card Validation

There are various HCV methods available that provide access to the ministry’s RPDB. Health care providers may review each of the methods to determine which most appropriately meets their needs based on current business practices and technical capabilities.

To register for HCV and for further information on HCV methods, please refer to the Health Card Validation Reference Manual available on the ministry’s website.

Back to top 


Health number Release

The ministry recognizes that patients may not always present for health services with the most recent health card information including the most recent version code.

If a provider cannot reasonably obtain the health card information from the patient or from existing records, the ministry, through ServiceOntario, has escalation processes to provide health numbers and version codes directly to providers.

There is both a form-based process as well as a 24x7 ServiceOntario Help Desk that offers providers accelerated release of health numbers/version codes. The 24x7 process is the preferred method as the ministry has undertaken a reduction in the amount of physical transferral of health numbers via mail.

The Health Number Release form (1265-84) facilitates claims payment by allowing providers access to health numbers and/or version codes if clients cannot produce their health card or if their health card was invalid at the time of service.

OHIP forms are available online at:
http://www.health.gov.on.ca/en/pro/forms/ohip_fm.aspx

For access to the 24x7 ServiceOntario Help Desk services, providers must first sign up for the service. To begin this process, an email containing the provider’s name and OHIP billing number can be sent to 24x7@ontario.ca. Please note that this service is only provided to recognized Ontario Health Information Custodians (as defined in the PHIPA).

Note: A person’s health number and version code is considered “personal health information” under the PHIPA.

Back to top 


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

 
  • Connect With Us
Facebook Twitter YouTube RSS