How OHIP Reimbursement Works: What Out-of-Pocket Medical Expenses are Eligible?
OHIP reimbursement is a rarely touched-on topic, and that’s because it rarely happens. You are only eligible for OHIP reimbursement in a select few situations. In this article, we’ll be covering the few situations where reimbursement can happen and how to get reimbursed by OHIP for medical expenses you paid for out-of-pocket.
OHIP Mostly Operates on Direct Billing
In Ontario, services eligible for OHIP coverage are typically covered via direct billing. The process of direct billing is carried out by your healthcare provider, and requires your OHIP card (or more specifically, your OHIP number).
If you are missing your OHIP card, you will need to pay out-of-pocket as it’s impossible to carry out direct billing without one. It’s a similar case if your card is expired.
What you pay is usually not eligible for reimbursement, but instead requires a different process for retroactive OHIP coverage. More about this below.
When OHIP Reimbursement Happens
Since direct billing is the main way OHIP covers eligible healthcare expenses, coverage via reimbursement is very rare, but can happen. OHIP reimbursement only happens when:
You Receive Out-of-Province or Out-of-Country Medical Services
For pre-approved out-of-province (OOP) or out-of-country (OOC) emergency medical services, you will be asked to pay upfront and then submit a claim with the Ministry of Health for reimbursement. A claim needs to be submitted within 12 months to be eligible for reimbursement.
An important factor here is pre-approval, which must be given by the provincial health ministry. Without approval, these expenses will not be reimbursed.
For the most part, OHIP won’t cover medical services outside of Canada. It’s strictly limited to emergency hospital or physician services, which means non-emergency expenses like prescription drugs, ambulance services, and dental care aren’t eligible.
Be Reimbursed for Non-Emergency Medical Expenses with a Travel Insurance Plan
If you frequently travel out-of-province or out-of-country, it’s a smart idea to invest in private travel insurance to cover any unexpected expenses. Travel insurance can cover what OHIP won’t, like emergency dental, prescription drugs, emergency air transport, lost baggage insurance, and much more.
Compare travel insurance quotes for free online, no broker needed!
Can I Be Reimbursed for Healthcare Charges Within Ontario
As long as the expense is eligible for OHIP coverage, yes, you can be reimbursed by OHIP for healthcare costs you paid for out-of-pocket in Ontario (see: What OHIP Covers).
However, this process wouldn’t work like a traditional reimbursement, where the amount you paid is reimbursed to your card in full. Instead, you’ll need to have your healthcare provider go through a refund process. More about what to do in this case below.
How to Have OHIP Reimburse Healthcare Charges Within Ontario
If you went to a walk-in clinic or other healthcare facility and had to pay out-of-pocket, here’s what to do to ensure OHIP covers the cost:
Return to the Healthcare Provider: Return to the same place where you paid out-of-pocket. Chances are you were charged out-of-pocket because you were missing your card or your card expired.
Ask for Direct Billing with OHIP: Let your healthcare provider know that your card is now valid and you would like your service directly billed to OHIP. It might help to have a receipt handy from when you paid for the service initially.
The Refund Process: Your healthcare provider will need to refund you and then re-bill the service to OHIP.
Get OHIP Coverage: If the service was eligible, the cost should be partially or fully covered by OHIP via direct billing.
To prevent any issues with getting retroactive coverage, you should get your health card renewed or replaced as soon as possible after it expires or is lost. It may be difficult to get a refund and re-bill for medical services you got charged for out-of-pocket if your card has been missing/invalid for a long time.