Ontario Works Directives 7.2: Health Benefits Legislative Authority Section 8 and 74(4) of the Act. Sections 55 and 59 of Regulation 134/98. Audit Requirements Adequate documentation is on file to support the issuance of mandatory and discretionary benefits. Benefits are provided only to benefit unit members who meet the eligibility criteria. Benefits do not exceed the maximum allowable amount where applicable, and are issued in accordance with any established time periods. Application of Policy Ontario Works health benefits are either mandatory or discretionary and are provided to a recipient or member of a benefit unit if the Administrator is satisfied that the recipient or benefit unit members meet the criteria for the provision of health benefits. Mandatory Benefits Drug Coverage Each member of a benefit unit is eligible for drug coverage for each month they are eligible for assistance. Drug coverage is limited to items covered by the Ontario Drug Benefit (ODB) Program and does not include the co-payment amount. Drug cards are issued monthly. A drug card may be issued for a recipient during a period of ineligibility for assistance due to non-compliance with participation requirements if it is determined by the Administrator that the participant requires drug coverage for a serious illness or health condition, and if failure to provide the drug card would result in detriment to the health of the recipient. Page 1 of 7
Dental Coverage for Children Dependent children and children in temporary care receive mandatory basic dental coverage as outlined in the MCSS Schedule of Dental Services and Fees for Mandatory Dental Coverage. Vision Care for Children Dependent children and children in temporary care receive coverage for the purchase and repair of lenses and frames. Children can receive a new pair of frames and lenses every three years without restrictions unless there are excessive requests for replacements which may be subject to restrictions if there is frequent loss, damage or negligence. Children can receive new lenses for glasses any time there is a change in prescription. The new lenses should be placed in existing frames where possible. If the cost of the frames and/or lenses exceeds the approved amount, the recipient may pay the difference in costs directly to the supplier. Where special frames or lenses are needed for medical reasons, the Administrator may approve this cost with appropriate documentation from the prescribing ophthalmologist, optometrist or general practitioner. Ontario Works does not cover the cost of contact lenses unless the Administrator is satisfied that they are medically necessary and appropriate documentation is provided. An Administrator may approve the cost of repairs to frames or lenses when the cost of repairs will not exceed the cost of replacement and there is proof of the need for repair. Eye Examinations The Ontario Health Insurance Plan (OHIP) covers the cost of eye exams for people under age 20 and people 65 years and over. For each member of the benefit unit who is between the ages of 20 and 64 Ontario Works will cover the cost of routine eye examinations once in every 24- month period. Adults between the ages of 20 and 64 who have medical conditions requiring regular eye examinations (i.e., treatments for infection, disease and injury) receive coverage for these eye examinations once in every 12-month period under OHIP. Page 2 of 7
Diabetic Supplies and Surgical Supplies and Dressings The amount provided is equal to the cost of the item and may be added to the person's assistance, or paid to a vendor directly, at the Administrator s discretion. The costs for diabetic and surgical supplies are covered when ordered under a physician s prescription and where the item is not otherwise covered from another source. Diabetic supplies include: o insulin pump and related supplies o alcohol swabs o blood glucose monitors o lancets o platforms o syringes o test strips Surgical supplies are items required by a person being treated at home for an injury, infection or other condition. Surgical supplies and dressings include: o accessories (adhesives, skin barriers) o catheters o colostomy, ileostomy and urinary supplies o condoms o diapers o drainage bags o incontinence and ostomy supplies o other surgical supplies as required Page 3 of 7
Travel and Transportation for Medical Purposes Travel and transportation costs for medical treatment are paid when the costs exceed $15 per benefit unit in a given month. Verification is required from the appropriate health provider confirming the person requires the service. Travel may be required for attendance at medical appointments, rehabilitation (therapy), a healing lodge, psychological counselling, drug and alcohol recovery groups (e.g., Alcoholics Anonymous, Narcotics Anonymous, etc.) or for other medical or health-related purposes. A monthly payment equivalent to a transportation pass can be issued if the participant is required to attend on-going appointments for medical or healthrelated purposes. Northern Ontario residents are required to apply for the Northern Health Travel Grant (NHTG) through the Ministry of Health and Long-Term Care for travel more than 100 kilometres, one way, to a physician specialist or health facility when referred by a northern practitioner. Pending eligibility for this grant, they should complete the Agreement to Reimburse and Assignment and Direction forms. Northern Health Travel Grant payments administered by the Ministry of Health and Long-Term Care in excess of the upfront amount provided under Ontario Works for the same trip are exempt as income and assets (see Directive 4.1: Summary of Assets and see Directive 5.1: Income and Exemptions for more information). Travel outside a municipality or First Nation, including out-of-province, for medical appointments should only be approved if treatment/therapy is not available in the geographic area in which a person resides; or, if treatment/therapy will be negatively impacted by a change in health care provider who is situated in another geographic area. Verification is required from the appropriate health provider confirming such travel is necessary. Travel costs may include the cost of meals and accommodation en route, if necessary. All travel costs should reflect the most reasonable and economical means of transportation. The Assistive Devices Program (ADP) The 25% consumer contribution for an assistive device is paid for any member of a benefit unit if these costs are not otherwise reimbursed. The Administrator may approve an amount to be paid if an assessment is required to determine eligibility for an assistive device under the ADP and there is no other source of funding for the assessment. Page 4 of 7
Batteries and Repairs for Mobility Devices The ADP does not cover costs associated with the maintenance of or repairs to assistive devices. The costs for batteries and repairs for mobility devices such as wheelchairs are paid if these costs are not otherwise reimbursed by another source. Discretionary Benefits Dental Care for Adults The Administrator may approve costs for dental services provided to adult members of the benefit unit for: emergency dental care (i.e., dental services which are necessary to relieve pain or for medical or therapeutic reasons); and dental care which supports the person s employability or participation requirements (e.g., orthodontic and denture services). Services provided for cosmetic reasons are not included. If the delivery agent has an agreement with the Ontario Dental Association (ODA) for services, the recipient can obtain required dental services and the delivery agent is billed directly by the ODA for such services. In areas where delivery agents do not have an arrangement with the ODA, the recipient is required to obtain an estimate of the cost to be approved by the Administrator before any such services can be provided. Administrators have the discretion to request an additional estimate if they consider the estimate to be unreasonable. Vision Care for Adults The Administrator may approve costs for eye glasses, including lenses and frames, repairs or replacements: when necessary as a result of a significant change in prescription; or if the benefit supports the person s employability or participation requirements. A prescription is required from an ophthalmologist, optometrist or physician before the cost of the frames and/or lenses may be approved. Page 5 of 7
Prosthetic Appliances The Administrator may approve costs for prosthetic appliances. Any device that replaces or strengthens a bodily function is considered a prosthesis. Prosthetic appliances may include such items as back braces, surgical stockings, artificial limbs and inhalators. The recommendation of an approved health professional and an estimate of the cost of such appliances are required. Hearing aids are also considered a prosthetic device. If the cost of a hearing aid is not covered under the ADP (if, for example, a hearing aid was purchased before authorization under ADP was granted or the cost is above the maximum limit provided by the ADP or the 25% consumer contribution), such costs can be covered as a discretionary benefit (see Directive 7.8: Assistive Devices for more information). Child Care Costs The Administrator may approve the cost of child care where a recipient requires child care in order to attend a medical appointment. Funerals and Burials The Administrator may approve the cost of a funeral and a burial or cremation. An amount of $2,250 is the recommended maximum for funeral and burial or cremation costs, however Administrators have the discretion to exceed this guideline amount. Approved costs above the guideline continue to be costshared at the current cost-sharing rate (see Directive 11.3: Cost Sharing for more information). A tombstone is not included in these costs. Grave markers, as required by a cemetery, and a "perpetual care" charge are included as part of the funeral and burial costs. In cases where a recipient or a benefit unit member resided in one geographic area and dies in another, the delivery agent in the place in which they ordinarily resided and received assistance is responsible for the funeral and burial or cremation costs. A transient or homeless person is deemed to reside in the geographic area in which the person received assistance. If the person was a transient and the family wants the body returned for burial in another geographic area from where the person died, the delivery agent where the person died is responsible for the costs of preparing the body and any transportation costs. The delivery agent that receives the body is responsible for funeral and burial or cremation costs. Municipalities are required by the statutes of the Public Hospitals Act and the Anatomy Act to cover the funeral and burial expenses for persons who died in Page 6 of 7
hospital and for unclaimed bodies. If a body has not been claimed by a relative for disposition, or by any other person who gives a bona fide undertaking to dispose of the body, it is the responsibility of the municipality where the body exists, to cover the cost of burial. Recovery of Funeral, Burial or Cremation Costs The Province of Ontario or a delivery agent can recover any amount paid for a funeral, burial or cremation from any person or organization liable for the payment of these expenses. Funeral, burial or cremation expenses are payable out of the deceased person s estate in priority to any other charge on the estate. If the delivery agent recovers its costs out of the estate, it may obtain an assignment of benefits from Canada Pension Plan (CPP) or Old Age Security (OAS) for which the deceased is eligible or may make a claim against the estate. This recovery of costs is sought from the person responsible for administering the estate (i.e., the executor if one is appointed under a will or a court appointed administrator). Care should be taken to maintain a complete record of monies received from the estate. Any monies received in excess of the costs associated with a funeral, burial or cremation must be returned to the estate of the deceased. Page 7 of 7