Regulation - LGIC

Proposed Amendments to Ontario Regulation 201/96 made under the Ontario Drug Benefit Act

Regulation Number(s):
Reg. 201/96
Bill or Act:
Ontario Drug Benefit Act
Summary of Proposal:
As announced in 'A Plan for the People - Ontario Economic Outlook and Fiscal Review' and further to the announcement made by the Minister of Health and Long-Term Care on June 30th, 2018, the government is fixing OHIP+ by focusing benefits on those who need them the most.

Beginning in March 2019, children and youth who do not have existing prescription drug benefits covered by private plans will continue to receive coverage through OHIP+. For those children and youth who are covered by private insurance, they will bill those plans.

Under a redesigned OHIP+, OHIP-insured children and youth 24 years of age and under who do not have private insurance would remain enrolled in the Ontario Drug Benefit program through the OHIP+ eligibility stream, and continue to receive benefits from the Ontario Drug Benefit program without co-payments or deductibles.

Children and youth (excluding social assistance recipients, recipients of home care, and residents of homes for special care or a community home for opportunity) with private insurance:
• Would access prescribed medicines as they did prior to the launch of OHIP+ through their private insurer as first payor
• Individuals or families who have significant out-of-pocket costs, despite having private insurance coverage, could apply for additional financial support through the Trillium Drug Program as was done prior to the implementation of OHIP+ on January 1st, 2018.
o The Trillium Drug Program is an application-based, income-tested program that is available to all OHIP-insured Ontarians, which helps with prescription drug costs for those with high drug costs compared to their household income. Households enrolled in the Trillium Drug Program would have an annual deductible (divided into quarters) based on their household income, which must be paid before benefits would be funded through the Ontario Drug Benefit program.
o Where the out-of-pocket costs for these children/youth do not reach the Trillium Drug Program deductibles, no public coverage would be provided (unless the child/youth becomes eligible through another eligibility stream, such as social assistance, home care recipient, etc.).
o Where the out-of-pocket costs for these children/youth meet the Trillium Drug Program deductibles, public coverage would be provided, subject to a maximum $2 co-payment per prescription that may be charged by a pharmacy.

Children and youth who are eligible for the Ontario Drug Benefit Program through social assistance, their receipt of home care services, or their residence in a home for special care or community home for opportunity would have no copayments or deductibles.

Private insurance is defined as any type of private plan, program or account which could contribute to the cost of any drug product, regardless of whether:
• the private insurance plan covers the particular drug for which coverage is sought,
• the child or youth or another person captured under the private insurance plan is required to pay a co-payment, deductible, or premium, or,
• the child or youth has reached their annual maximum under the private insurance plan and no further coverage is available.

Amendments to O. Reg. 201/96 made under the Ontario Drug Benefit Act are required to implement these changes. The text of the proposed regulatory amendments is available for download below.
Analysis of Regulatory Impact:
It is estimated that prescription drug costs for children and youth represent 5-8% of total prescription drug expenditures amongst private drug plans. It is expected that employers/insurers who were not paying for prescription drug coverage for children/youth under their existing benefit plans (due to the implementation of OHIP+ on January 1, 2018) would see their costs increase. These costs would vary based on the type of plan and the costs incurred for providing prescription medicines for children and youth who were previously eligible for coverage under OHIP+.

There are different types of private insurance plans utilized in Ontario and the proposed OHIP+ redesign would impact each differently. Insurance premiums are generally tied to health benefits and reflect all expected costs that will be incurred (e.g. dental, vision, drugs, supportive health services, etc.). Drug coverage is typically not insured separately. Insurers look to each employer's past year's claims experience, demographics of the plan members, and forecasts for new expenditures in the coming year to set premiums. Therefore, depending on the plan, the OHIP+ redesign may have an impact on insurance premiums.

The redesigned OHIP+ may also have an impact on pharmacies. The Pharmacy Validation of Eligibility Approach would require the pharmacy to ask the child/youth/agent whether the child/youth has a private drug plan each time a prescription is filled. This may result in increased costs to pharmacies as additional time may be required to validate whether an individual has private insurance
Further Information:
Proposal Number:
18-HLTC029
Posting Date:
January 2, 2019
Comments Due Date:
January 31, 2019
Contact Address:
Ministry of Health & Long-Term Care
Ontario Public Drug Programs
5700 Yonge St., 5th Floor
Toronto ON M2M 4K5