Everything You Need To Know About The OHIP Schedule of Benefits
- 6 min read
What is the Ontario Health Insurance Plan (OHIP)?
Before we discuss the Schedule of Benefits (SoB), we must discuss what the Ontario Health Insurance Plan (OHIP) is. OHIP is a government insurance plan for Ontario, funded by payroll deductions by employed Ontario citizens, Ontario business owners, and the government of Canada.
Any permanent citizen in Ontario has access to free preventative and emergency services under OHIP, covered by taxes. There are other criteria to determine eligibility for OHIP, which are found here. What determines which services are covered by OHIP? This is where the SoB comes in play.
What is the Ontario Schedule of Benefits?
The Schedule of Benefits (SoB) is essential for healthcare providers in Ontario. It establishes the insured services covered by OHIP. It sets out the fees and requirements for the 6000 or so services across 980 pages. It is a vital piece in managing the cost and delivery of healthcare services in Ontario. It reflects a balance between physician advocacy and governmental oversight.
The Ontario Ministry of Health negotiates with the Ontario Medical Association, which represents physicians in Ontario, to cover fees for medical services, new services to be added, and adjustments to existing services.
The SoB mainly runs on a fee-for-service basis, where physicians are paid on the number and type of services they provide. However, there are other compensation models, such as alternate funding plans or capitation, that are also included.
Periodically, the SoB is updated to keep up with changes within medical practices or government policy. For example, during the COVID-19 pandemic, billing codes related to the disease were added. At the time of writing, the latest update to the SoB was February 20, 2024, and has been effective since April 1, 2024.
The SoB works together with something called the Fee Schedule. The Fee Schedule determines the fees associated with each service code. Often, the Fee Schedule and SoB are not updated at the same time, resulting in discrepancies in fee information.
The services covered in the SoB not only have a significant impact on how healthcare providers are compensated, but also patient access to care. Additionally, the public nature of this increases the transparency – ensuring patients understand the healthcare coverage and costs involved.
So, what’s in the SoB? Do not worry, we outlined the key points of the five main sections below.
1. General Preamble
It is highly recommended that you read the General Preamble at least once because it affects all physicians. It is the first 113 pages (GP1 – GP113), so just relax and take your time. More information on the General Preamble is shown further down.
The surgical procedures also have their own specific preamble which should be read if you practice within those specialties.
2. Consultations and Visits
This section outlines the fee codes and payment rules for patient visits. These include all consultations and their subsequent visits, counselling, psychotherapy, and interviews. More information for each specialty is located within this section as well.
3. Specialty Sections
This section lists fee codes related to specialty, non-surgical procedures, including:
- Nuclear Medicine – IN VIVO
- Positron Emission Tomography (PET)
- Radiation Oncology
- Diagnostic Radiology
- Clinical Procedures associated with Diagnostic Radiological Examinations
- Magnetic Resonance Imaging (MRI)
- Diagnostic Ultrasound
- Pulmonary Function Studies
- Diagnostic and Therapeutic Procedures
- Obstetrics
4. Surgical Procedures
This section lists a Surgical Preamble and fee codes related to surgical procedures.
- Surgical Preamble
- Integumentary System Surgical Procedures
- Musculoskeletal System Surgical Procedures
- Respiratory Surgical Procedures
- Cardiovascular Surgical Procedures
- Haematic and Lymphatic Surgical Procedures`
- Digestive System Surgical Procedures
- Urogenital and Urinary Surgical Procedures
- Male Genital Surgical Procedures
- Female Genital Surgical Procedures
- Endocrine Surgical Procedures
- Neurological Surgical Procedures
- Ocular and Aural Surgical Procedures
- Spinal Surgical Procedures
5. Appendices
Most appendices are only there to provide more information. However, Appendix D is included in law through Regulation 552.
Each chapter also has subchapters that include different specialties (e.g., Cardiology) or anatomical areas (e.g., Pelvis). It is recommended that you also read the sections specific to your practice there.
The General Preamble Breakdown
Type of Definitions
General definitions and phrases are italicized throughout the General Preamble and signifies that additional information is available in the Definitions Sections. The second group of defined terms refers to maximums, minimums, and time or unit-based services.
Prefixes and Suffixes
Fee codes, or billing groups, are 5-character codes that clarify the type of service.
Consultations and Assessments
- Prefix usually differentiates the service location. The A prefix must be used when submitted a claim for consultations and assessments except in the following situations when the codes listed below must be used:
- C = acute care hospital, non-emergency in-patient services
- W = long term care institution, non-emergency in-patient services
- H1xx = emergency room patient, services rendered by a physician on duty
- H3xx = rehabilitation unit – services rendered by a specialist in Physical Medicine
- The first two numbers indicate the physician specialty, except for numbers like 9x.
- e.g., 00 = GP, 13 = internal medicine
- The third number indicates the type of service:
- 3 = general or specific assessment
- 5 = consultation
(Prefix A – Out-patient; first two numbers 13 – Internal Medicine; third number – Consultation)
Suffixes: have different meanings depending on the type of fee schedule code they are used with.
- Diagnostic Tests:
- B indicates a technical fee. This provides compensation for the cost of the equipment, personnel, supplies, and performing the procedure. This is commonly referred to as “T fee” or “H fee”.
- C: indicates a professional fee. This provides compensation for the test interpretation and other professional elements done by the physician. This is commonly referred to as “P fee”.
- Surgical Procedures:
- A: Surgeon
- B: Surgical Assistant
- C: Anaesthesiologist
Diagnostic Codes
Certain assessments require a diagnostic code to accompany them to ensure proper documentation, billing, and treatment planning. These are usually applied during medical examinations, consultations, and diagnostic tests. For example, 042 is AIDS and 345 is epilepsy – the list is extensive. You can learn more about diagnostic codes from RMA or from page GP26 on the SoB.
Premiums
Premiums are additional codes payable in addition to the amount payable for a service. There are specific criteria for the different kinds of premiums. Some examples include:
- Chronic Disease Assessment Premium
- After Hours Premiums
- Special Visit Premiums
- MRP Visit Premiums
In addition to code-based premiums, there are also premiums which are applied as a lump sum amount on the OHIP Remittance Advice. These are automatically calculated by OHIP on qualifying services which are based on specific criteria. Some examples include:
- Age-based Fee Premiums
- Internal Medicine Office Assessment Premium
- Hospitalist Premium
- Focused Practice Psychotherapy Premium
The specific criterion for each premium varies by type. Our staff know all the premiums like the back of their hand, so if you ever need help optimizing your billing, make sure to contact us to sign up!
Next Steps
A 980-page document is never fun to read over, but reading the General Preamble and sections specific to your practice is highly recommended. You may find it helpful to highlight certain sections that pertain to your practice to help you better navigate the SoB.
The link to the full SoB is here. It is only available in English. The fee schedule can be found here. Additionally, there are amendments for emergency department diagnostics under the Health Insurance Act (2005) available here. Lastly, additional information is available on the official Ontario SoB page.
At RMA, with over 40 years of experience, we know the ins and outs of fee codes and payment rules across all the specialties. Our staff is always happy to help!
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