Ontario (ON)
Ontario Health Coverage
Financing

Premiums

Employers pay an Employer Health Tax (EHT) at a graduated rate ranging from 0.98% to 1.95%, depending on total annual payroll. Private sector employers are except for the first $400,000 of annual payroll.

A Fair Share Health Care Levy (FSHCL) is part of the surtax on Ontario income tax. It is 20% of tax over $3,845 plus 36% of tax over $4,800.

Utilization Fees

• Chronic Care patients age 18 and over pay $1,252.04 per month after the first 60 days
• Nursing Home/Home for the Aged - $41.16 per day (Income testing available)
• Ambulance - $45 per trip when medically necessary
• Ambulance - $240 flat rate if not medically necessary
• Prescription Drugs - $2 per prescription

Extra Billing

Extra billing by physicians is prohibited.

Billing and Payment

Hospital Bills

Hospitals receive payments directly from the provincial plan for insured services.

Physician's Bills

• participating physicians bill the plan directly and receive payment from the plan.
• non-participating physicians bill the patient and furnish information to enable the patient to submit a claim to the provincial plan. The plan reimburses the patient (extra billing is not permitted).

Private Insurance

Same as That Provided by the Provincial Plan

Insurers can provide basic coverage during the 3 month waiting period for persons taking up residence in Ontario.

Private insurers may not provide coverage for all or any part of insured services other than:

• any part of the cost of hospital, ambulance, and nursing home services that is not paid by the provincial plan
• cost of non approved surgical extractions and associated charges for general anaesthetic

Over and Above That Provided by the Provincial Plan

Private insurers may provide coverage for all or any part of the following services:

• Hospital: private or semi-private accommodation
• Physicians: no private insurance permitted
• Ambulance: the utilization fee and any charges not paid by the provincial plan
• Laboratory: if service not covered by the plan
• X-rays: if service not covered by the plan
• Optometrists: if service not covered by the plan
• Chiropractors: the portion not paid by the provincial plan
• Osteopaths: any charges made for any service provided after the yearly maximum has been reached
• Chiropodists or Podiatrists: any charges made for any service provided after the yearly maximum has been reached
• Physiotherapists: any charges made by licensed physiotherapists working in an unapproved facility, not listed in Schedule 5
• Special Nursing: any charges
• Nursing Homes or Homes for the Aged: the portion not paid by the provincial plan
• Chronic Care: the portion not paid by the provincial plan
• Home Care: the portion not paid by the provincial plan
• Dental: other than in hospital) and also for insured but non approved surgical extractions as well as general anaesthetic, when performed in the hospital
• Drugs: other than covered by the provincial plan
• Outside Province/Country: any amounts charged that are not paid for by the provincial plan

Third Party Liability

An insured person, who incurs medical expense on account of wrongful acts of a third party may take action to recover losses, but must include a claim on behalf of the Health Services Insurance Division of the Department of Health, for the cost of insured services.

If no action is commenced by an insured person, after notice to the insured person, the Division may take action in his name for recovery of insured services costs, and may affect settlement of its claims without prejudice to the rights of the insured person to recover other damages.

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