OPIP Frequently Asked Questions

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1 Eligibility: 1 Who is eligible to apply for OPIP? You are eligible to apply if you are a physician (excluding a resident) who: resides in Canada; is registered with the College of Physician and Surgeons of Ontario; is engaged in providing medical services in the province of Ontario for at least 15 hours per week on average or; is a member in good standing of the Ontario Medical Association or, if not a member, has paid all dues and assessments owing under the Ontario Medical Association Dues Act, For the purposes of OPIP eligibility, medical services include the provision, study, and administration of medical care, and include, but are not limited to: physicians in medical practice laboratory physicians company medical directors insurance company physicians OHIP and WSIB physicians hospital and medical clinic administrators medical school teachers medical researchers hospital committee work The following do not qualify as medical services: on-call time Continuing Medical Education (CME) or other study time Board and committee work outside a hospital, and volunteer/community work that is not providing medical services For full eligibility criteria please refer to Resource: Eligibility for OPIP Physician Health Benefits Program at opip.ca. 2 What is the Physician Health Benefits Program (PHBP)? PHBP is the subsidized program negotiated with the Ontario government which provides you and your family with affordable health coverage. Administered by Ontario Physician Services Inc., PHBP offers core plans as well as additional top-up options at your own cost. 3 Can I apply for OPIP if I have just completed residency? If you have successfully completed residency, you may enrol if you anticipate working at least 15 hours per week on average and if you enrol within 90 days of graduating, you do not have to provide medical evidence. 4 What happens to my OPIP coverage once I retire from active practice? Once you retire from active practice, you may continue as a member of OPIP but you are no longer eligible for the government subsidization for the Critical Illness insurance and Health plans. To continue your coverage once you have ceased active practice you must: have been covered by the program for at least 12 months; provide written notification of your change in eligibility and your intent to continue the coverage within 60 days; and pay the full cost of the plan; Page 1 of 7

2 be under age 70 for the Critical Illness coverage to continue. If you do not meet all of these criteria, then your coverage will terminate. 5 Under what circumstances would I no longer qualify for the government subsidy for OPIP Health and Critical Illness insurance? You would no longer qualify for funding if any of the following conditions are met: you cease to be a resident of Canada; you stop providing medical services for at least 15 hours per week on average in Ontario; you are no longer registered with the College of Physicians and Surgeons of Ontario; or you are no longer an OMA member or cease to pay OMA dues and assessments. If you once again meet all the eligibility requirements and have continued paying the premiums so that your coverage was maintained consistently, you may become eligible to re-enrol for the government subsidization. Contact us at If you stop working the minimum number of hours required per week as the result of a disability or parental leave of absence, you may continue to qualify for subsidization for up to 12 months upon providing notification. Contact us at Program Enrolment: 6 How can I enrol in OPIP? You can enrol by completing the form that is included in the enrolment package you received. If you didn t receive a package and are eligible to participate in this program, please contact us at or to request a package. You can also find a newly eligible or late entrant enrolment form and information on the program at opip.ca. 7 What is the OPIP plan year? The plan year is January 1st to December 31st. Annual Contribution: 8 How do I pay my annual contribution for OPIP? When you complete your enrolment form, you are asked to apply for funding which can be on behalf of yourself or your corporation, depending on your personal tax situation. You are then asked to provide banking information so that the provider can withdraw your annual contribution from the bank account you designate. 9 Can I pay my OPIP annual contribution by cheque or credit card? Cheque and credit card payments are not available under this program. To help contain administrative costs, annual contributions can only be remitted by pre-authorized debit. Page 2 of 7

3 10 Why do I have to pay the OPIP annual contribution why doesn t the government subsidization cover the entire premium? The government subsidization, provided through the Physician Health Benefit Program and administered by Ontario Physician Services Inc., was never intended to cover the entire premium, but was intended to give Ontario physician s access to a comprehensive program at unparalleled rates. Your contribution will not only give you good value for you and your family, but also provide stability in the program for physicians to enjoy for the years to come. 11 If I enrol for OPIP mid-year, is the annual contribution pro-rated? The contribution cannot be pro-rated. You are required to pay the full amount. 12 If I terminate my OPIP coverage mid-year, do I receive a pro-rated refund of my annual contribution? The annual contribution is non-refundable. 13 Can I shop around? Is there a better deal than OPIP? Please feel free to shop around. We are confident that you won t find a more comprehensive package of coverages comparable with OPIP. If you choose to look around, please be careful you do not miss the deadline to apply without medical evidence, as the consequences could be very negative for you. If you do decide to change providers it s important to ensure that your new policy is in effect before you cancel. This means you should not cancel your coverage with the OMA until all of the following have occurred: you have completed all new applications and requirements; you have been approved by another insurer; you have received your policy or certificate and; they have accepted your payment without conditions. Health and Health Plus Insurance 14 Why did you change the name from OPIP Extended Health Care to Health? The name was changed to achieve simplicity in naming structure and to better position the concept that Health is the government subsidized foundational coverage for your health and well-being. This is distinguished from Health Plus which provides you with the self-funding option to add to your coverage enabling you to customize the protection for your needs. 15 Are there benefit maximums under the OPIP Health & Health Plus insurance programs? There are benefit maximums. Please refer to the Plan Details sheet available on opip.ca. Are pre-existing medical conditions excluded from coverage? If you apply for the government funded benefits within 90 days of eligibility, your application does not require medical evidence and no pre-existing medical condition exclusions will be added to your coverage. If you are a late applicant, you are required to provide medical evidence and pre-existing medical condition exclusions may be added to your coverage if your application is approved. Page 3 of 7

4 16 Is a prescription drug card available under the OPIP Health & Health Plus plans? There is a Pay-Direct drug card that can easily be downloaded from sunlife.ca/member. 17 What expenses are not reimbursed under the OPIP Health & Health Plus plans? The plans do not cover: cosmetic surgery except to the extent necessary to repair disfigurement due to an injury sustained while insured; an examination by or the services of a physician or surgeon if required for the use of a third party; dental expenses or work or treatment on the teeth or gums; drugs for the treatment of sexual dysfunction; treatment for smoking cessation, drug treatment for obesity, hair growth stimulants, and drugs available without a prescription; vision care, including eye exams, glasses and contact lenses (not covered under Health only) care, treatment, services or supplies which are not recommended and approved by a physician. Any services or supplies that are not approved by Health Canada s Health Protection Branch that are not usually provided to treat a medical condition or disease, or are deemed to be experimental in nature, and/or may be in the testing stage, will not be reimbursed. Please refer to the Plan Details sheet available on opip.ca. In addition, healthcare expenses are not covered if they result directly or indirectly from: declared or undeclared war, insurrection, or rebellion, whether or not you or your spouse or dependent children are actually participating; participation in a riot or act of civil disobedience; the act of committing or attempting to commit a criminal offence. 18 Is there a time limit on submitting an expense for reimbursement through my OPIP Health or Health Plus plan? You have 180 days after the end of the benefit year (December 31) to submit your claim expenses that were incurred during that benefit year. After the 180 days, those claims will be null and void. 19 Do these OPIP plans include out-of-province/country travel coverage? Yes, these plans cover you for emergency out-of-province/country medical expenses. These plans cover up to $2,000,000 lifetime maximum per insured person during the first 90 days of travel for insured persons under age 70, and for the first 30 days of travel for insureds age 70 and older. 20 What is considered a life-event change for OPIP Health and Health Plus purposes? A life-event change is defined as follows: marriage, separation or divorce; a spouse or dependant child becomes eligible for coverage, or no longer qualifies as an eligible dependant; the birth or adoption of a child; accepting legal guardianship of a child; the death of a spouse or child; the loss or gain of insurance under your or your spouse s insurance plan (for example, due to a change in your or your spouse s/partner s employment). Page 4 of 7

5 21 What if I am currently enrolled in OPIP Health and Health Plus and experience a life-event change? If there are people in your life who become qualified for coverage as a result of a life-event change, you can add them to the plan with no medical evidence as long as you apply within 90 days of the effective date of the life-event change. 22 What if I am not currently enrolled in OPIP Health and Health Plus and experience a life-event change, can I get into the plan without medical evidence? Medical evidence must be provided. 23 How do I file a claim under OPIP Health and Health Plus? Once you are enrolled in OPIP, you can register at sunlife.ca/member to submit most of your Health and Health Plus claims electronically or print claim forms. For Critical Illness claims, contact us at , and a representative will send you a claim form for completion. 24 How do I submit a drug claim under OPIP Health and Health Plus? Your OPIP Health and Health Plus includes a drug card. There is no need to submit a claim for drug expenses. Simply present your drug card to the pharmacist when filling a prescription and the pharmacist will submit your claim electronically on your behalf. Critical Illness Insurance 25 Why do I have to be under age 65 to apply for OPIP Critical Illness insurance and why does this coverage terminate at age 70? Age restrictions are common in life and health insurance solutions and are necessary to help contain costs and ensure the financial viability of the plan. 26 Is OPIP Critical Illness insurance available to my spouse or children? Critical Illness insurance is available to you only, provided you are under age 65 when you apply and meet all the other eligibility criteria. 27 Can I apply for more than $50,000 of Critical Illness insurance under OPIP? OPIP Critical Illness insurance provides a flat benefit of $50,000. Additional Critical Illness coverage is available at competitive premiums through OMA Insurance if you would like to apply. 28 What can I use the OPIP Critical Illness insurance payment for? Your tax-free lump sum payment 1 gives you the freedom and flexibility to use the funds as you see fit. For example, you can use the money for: out-of-country treatment, travel and expenses experimental treatment medical equipment; home modification private nursing or personal support worker mortgage or other debts Page 5 of 7

6 29 If I become disabled and receive a Disability insurance benefit, would that amount be reduced when my OPIP Critical Illness insurance benefit is paid? The Critical Illness insurance benefit is unaffected by any other coverage you have. 30 Will my OPIP Critical Illness insurance benefit be reduced based on my illness or because of other benefits I have? Upon approval of your claim, you will be paid $50,000. The amount will not be reduced due to the nature of your illness or other benefits you may receive. 31 If I do not currently have OPIP Critical Illness and experience a life-event change, can I get into the plan without medical evidence? You must provide medical evidence. 32 If I am diagnosed with more than one illness, do I receive more than one OPIP Critical Illness insurance payment? Any Critical Illness benefit is payable only on the first covered critical illness conditions for which a Diagnosis is effective, or Surgery is performed, and then the critical illness insurance ends, except as provided under the cancer and benign brain tumour Critical Illness condition definitions. OPIP Dental & OMA Dental Plus Insurance 33 Are there benefit maximums under the OPIP Dental & Dental Plus insurance programs? There are benefit maximums. Please refer to the Plan Details sheet available on opip.ca. 34 What is not covered under the OPIP Dental and Dental Plus? Both OPIP Dental and Dental Plus do not cover: services or supplies payable or available (regardless of any waiting list) under any government-sponsored plan or program unless explicitly listed as covered under this benefit; services or supplies that are not usually provided to treat a dental problem; procedures performed primarily to improve appearance; the replacement of dental appliances that are lost, misplaced or stolen; charges for appointments that you do not keep; charges for completing claim forms; services or supplies for which no charge would have been made in the absence of this coverage; supplies usually intended for sport or home use, for example, mouthguards; procedures or supplies used in full mouth reconstructions (capping all of the teeth in the mouth), vertical dimension corrections (changing the way the teeth meet) including attrition (worn-down teeth), alteration or restoration of occlusion (building up and restoring the bite), or for the purpose of prosthetic splinting (capping teeth and joining teeth together to provide additional support). OPIP Dental does not cover: charges related to implants, including surgery charges Page 6 of 7

7 In addition, dental work resulting from the following will not be covered for both OPIP Dental and Dental Plus: the hostile action of any armed forces, insurrection or participation in a riot or civil commotion; teeth malformed at birth or during development; transplants and reposition of the jaw; experimental treatments; participation in a criminal offence. 35 If I cancel my OPIP Dental or Dental Plus, can I re-apply? Dental or Dental Plus cannot be cancelled within the initial 12 months of coverage. After this first year of coverage, it may be cancelled but there is a two year waiting period before you may re-apply. 36 How do I switch from OPIP Dental to Dental Plus and vice versa under OPIP? Your opportunity to switch occurs only once a year, during the renewal period effective January How do I file a dental claim under OPIP? You can file a dental claim either through electronic submission from your dentist s office or visit sunlife.ca/member for online submission. 38 Is there a time limit on submitting an expense for reimbursement for my OPIP Dental and Dental Plus? You have 180 days after the end of the benefit year (December 31) to submit your claim expenses that were incurred during that benefit year. After the 180 days, those claims will be null and void. For Help: 39 Where can I get more information or assistance on OPIP? Contact us at or 1 Diagnosis of a critical illness such as cancer, heart attack or stroke must occur after the effective date of coverage and you must complete a survival period (usually 30 days). Based on current tax laws, we believe that any cash benefit from a group critical illness insurance plan will not presently be taxed when the premiums are paid for by the plan member and the benefit is payable to the plan member. Sun Life Assurance Company of Canada Critical Illness insurance is underwritten by Sun Life Assurance Company of Canada, a member of the Sun Life Financial group of companies. This document provides the highlights, but not all the details of the insurance coverages provided under the OMA Priority Insurance Program. The complete terms, conditions, exclusions and limitations governing the insurance coverage are found in the group insurance policies issued to the Ontario Medical Association Page 7 of 7

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