April 2017

2.9 - Medical Reviews

Summary of Legislation

To be eligible for ODSP income support, a person must meet all eligibility criteria under the ODSP Act.

When a determination of disability is made under section 4(1) of the ODSP Act, a medical review date may be assigned under section 5(1) of the regulatory authority unless there is no likelihood of improvement of the person’s disability.

If upon the medical review, the person is no longer a person with a disability; or if the person fails to submit the Medical Review Package (MRP) within the prescribed 90-day time frame, the person is no longer eligible for income support and benefits.

Legislative Authority

Sections 4(1), (2); 10(1), (2) of the ODSP Act
Sections 4(1); 5(1), (2); 9; 16(5); 18; 46(1), (2); 47; 57 and 64 (1),(2),(3) of the ODSP Regulation

Summary of Directive

The Directive outlines:

  • The role of the Disability Adjudication Unit (DAU).
  • Medical reviews in unique circumstances.
  • Types of medical review decisions and impact on eligibility for ODSP income support.
  • Internal review and the appeal process for a medical review decision.

Intent of Policy

Medical reviews assist in confirming that recipients and spouses with a disability continue to qualify for ODSP.

A recipient or spouse, who is a person with a disability as defined by the ODSP Act, and granted income support and benefits with a medical review date, is subject to a medical review to confirm his or her ongoing eligibility. At the time of being found to be a person with a disability, the person is informed if a medical review date has been assigned.

Application of Policy

A recipient or spouse with a disability undergoing a medical review is eligible for ODSP income support as a person with a disability during the medical review process as long as he or she continues to meet all other eligibility criteria under ODSP.

The DAU is responsible for administering and conducting the medical review.

The DAU notifies and sends the MRP to a recipient or spouse whose medical review is due.

Completion of the Medical Review Package (MRP)

The MRP is the ministry approved forms used for the purpose of conducting a medical review.

The MRP includes the following:

  • Medical Form Part A and Medical Form Part B
  • Summary of Disability Decision
  • Consent to the Release of Medical and Related Information
  • Self Report Form
  • Instruction Sheet
  • Information for Health Care Professional
  • Envelope (to submit the application directly to the DAU)

The following prescribed health care professionals who are members of their respective regulatory college in Ontario may complete:

Medical Form Part A:

  • Physician
  • Psychologist or Psychological Associate
  • Optometrist
  • Nurse Practitioner

Medical Form Part B has two sections, the Health Status Report (HSR) and the Activities of Daily Living (ADL)

The HSR may be completed by:

  • Physician
  • Psychologist or Psychological Associate
  • Optometrist
  • Nurse Practitioner

The ADL may be completed by:

  • Physician
  • Psychologist or Psychological Associate
  • Optometrist
  • Nurse Practitioner
  • Occupational Therapist or Physiotherapist
  • Audiologist or Speech Language Pathologist
  • Chiropractor
  • Social Worker

The Self Report form is optional, and can be completed by the recipient or a trustee, family member, a friend or caseworker.

The MRP is only considered complete for the purpose of conducting a medical review when the Medical Form Part A, and where appropriate Medical Form Part B is completed by the prescribed health care professional, the Consent to the Release of Medical and Related Information is completed by the recipient or a designate.

The MRP is to be completed and returned to the DAU within the prescribed 90-days.

If a recipient encounters difficulty getting their MRP completed or submitted within the 90-day prescribed time frame, the person may contact the DAU directly and ask for an extension. An extension will be provided for extenuating circumstances such as hospitalization, detained in a lawful place of confinement or illness.

Recipients are encouraged to have their health care professional submit additional medical and supporting information with their MRP, e.g. specialist reports, psychological assessments, radiology reports, functional assessments etc., where needed.

If a recipient or spouse with a disability receives a MRP and requires a replacement MRP due to loss or destruction of the original, the local office should instruct the person to contact the DAU directly to request a replacement.

Medical Review Unique Circumstances

1. Income Support Cancelled Unrelated to Disability Status

A medical review is not conducted for a person whose income support has been cancelled for reasons unrelated to his or her disability status.

2. A Person Detained in a Lawful Place of Confinement

Where the recipient or spouse with a disability is detained in a lawful place of confinement and his or her medical review is due, the medical review will be deferred until the person is released from his or her lawful place of confinement.

In cases where a recipient or spouse with a disability enters a lawful place of confinement and his or her medical review has already commenced, the DAU, in consultation with local office staff will determine if the review should continue or be deferred based on the person’s ability to participate in the medical review process.

If deferred, the DAU shall only proceed with the medical review upon notification from local office staff that the person is no longer detained in a lawful place of confinement.

3. Temporarily Residing in a Hospital, Psychiatric Facility, or a Substance Abuse Recovery Home (SARH)

Where a recipient or spouse with a disability is temporarily in a hospital, psychiatric facility1, or a substance abuse recovery home (SARH), and his or her medical review is due, the medical review will be deferred until the person is discharged from the facility.

In cases where the recipient or spouse with a disability is temporarily in a hospital, psychiatric facility or a SARH and the medical review process has already started, the DAU, in conjunction with the local office staff will determine if the review should continue or be deferred based on the person’s ability to participate in the medical review process.

If deferred, the DAU shall proceed with the medical review upon notification from local office staff that the person has been released.

4. A Person Residing in an Interval or Transition Home

Where the recipient or spouse with a disability is residing in an interval or transition home for abused women and her medical review is due, the medical review will be deferred until the person returns to her former or new principal residence in the community.

In cases where the medical review has already commenced the DAU, in conjunction with local office staff will determine if the review should continue or be deferred based on the person’s ability to participate in the medical review process.

If deferred, the DAU shall only proceed with the medical review upon notification from local office staff that the person is no longer residing in an interval or transition home.

5. Approved Absence from Ontario

Where the recipient or spouse with a disability is on an approved absence from Ontario, and his or her medical review is due, the medical review is deferred until the person returns to Ontario.

In cases where the recipient or spouse with a disability is on an approved absence and his or her medical review has already commenced, the DAU in conjunction with local office staff must determine if the review should continue or be deferred based on the person’s ability to participate in the medical review process.

6. Appeal of Decision of Financial Ineligibility Pending

Where an appeal has been made to the Social Benefits Tribunal (SBT) regarding financial eligibility and his or her medical review is due, the medical review shall proceed.

7. A Person in Receipt of Canada Pension Plan Disability (CPP-D) or Quebec Pension Plan Disability (QPP-D)

Where a recipient or spouse with disability was found “to be a person with a disability” is scheduled to undergo a medical review and is also in receipt of CPP-D or QPP-D as a prescribed class, a medical review is not to be conducted.

Recipients in receipt of CPP-D or QPP-D are members of a prescribed class and are not required to undergo a medical review.

However, if a recipient should lose their prescribed class status (i.e., no longer eligible for CPP-D or QPP-D) and had a medical review date assigned, the recipient is then subject to a medical review.

Rapid Reinstatement & Medical Reviews

ODSP adjudicated recipients or spouses with a disability who have been rapidly reinstated are subject to a medical review where a medical review date has been set. If the medical review date has already passed, and the person has not undergone a medical review at the time of reinstatement, a new medical review date will be set by the DAU at the time of rapid reinstatement.

The local ODSP Office is responsible for advising the DAU when a person is rapidly reinstated. The DAU is responsible for notifying the person of the upcoming medical review and for conducting it.

NOTE: Recipients or spouses with a disability whose income support was cancelled because of being found to no longer be a person with a disability as a result of a medical review are not eligible for rapid reinstatement. If the person wishes to reapply for ODSP, they are required to submit a new application and be adjudicated by the DAU.

Types of Medical Review Decision and Impact on Eligibility for ODSP Income Support

1. Failure to Submit the MRP Within the Allotted

Timeframe

If a recipient or spouse with a disability fails to submit the MRP within the allotted timeframe, income support shall be cancelled unless the person has a spouse who is eligible for ODSP income support in his or her own right. In those cases, income support shall be reduced accordingly. The cancellation of or reduction to the amount of income support and benefits shall be effective the first day of the month following the month that the MRP was due.

IMPORTANT

Persons who are unable to submit their MRP within the prescribed 90-day timeframe must contact the DAU directly, and can ask for an extension of time to submit the MRP. The DAU will grant an extension of time for extenuating circumstances, e.g. hospitalizations, detained in a lawful place of confinement, illness, difficulties encountered in getting the MRP completed etc.

If the MRP is received late by the DAU but within 30-days past the MRP due date, and an extension of time has not been requested, the DAU will accept the late MRP and the person will be reinstated to the effective date of cancellation or reduction, provided that all other eligibility requirements continue to be met.

As well, the DAU may grant an extension of time to submit the MRP after the cancellation or reduction of income support for failure to submit the MRP in exceptional cases. If the DAU grants such an extension, the person will be reinstated to the effective date of cancellation or reduction.

2. Found to continue to be a Person with a Disability

If a person is determined to continue to be a person with a disability as a result of their medical review, he or she will continue to receive income support and benefits, as long as they continue to meet all other eligibility criteria for ODSP.

A new medical review date may be set unless there is no likelihood of improvement in the person’s medical condition. The medical review date cannot be appealed to the SBT, as the SBT does not hear appeals about setting a medical review date.

3. Found no longer to be a Person with a Disability

If a person is determined to no longer be a person with a disability upon their medical review, income support is cancelled unless the person has a spouse who is eligible for ODSP income support in his/her own right in which case income support is reduced accordingly.

In order to assist the person in adjusting to the change in his or her financial circumstances, income support will be extended for a period of three months following the effective date of the DAU’s decision. Income support is effectively cancelled or reduced on the first day of the fourth month following the month of the DAU’s decision.. It should be noted that all other eligibility criteria for ODSP must continue to be met during this period.

For the purpose of calculating the budgetary requirements for those three months, the person who underwent the review shall continue to be considered a person with a disability.

If the recipient or the spouse fails to meet all other eligibility criteria for ODSP, e.g. income in excess during this three-month transition period, the extension of income support is to be cancelled and an overpayment set up for only the period of financial ineligibility.

4. DAU or the Social Benefits Tribunal Overturns An Adverse Medical Review Decision

Where the DAU overturns a decision of no longer a person with a disability as a result of an internal review or prior to the SBT hearing, or the SBT grants the appeal, income support is to be reinstated where a cancellation or reduction has already been implemented.

The local ODSP office is responsible for reinstating the recipient or the spouse with a disability and making the appropriate adjustments. Income support should be reinstated or adjusted back to the effective date of cancellation or reduction in income support.  Any arrears owing should be paid to the benefit unit as soon as possible.

Examples of Medical Review Decisions Where Income Support is Cancelled or Reduced

Medical Review Scenario Impact on Income Support

MRP not submitted in 90 days

A single recipient’s MRP is not submitted to the DAU within the prescribed 90-day time period.

The MRP due date is May 16, 2014.

An extension of time to submit the MRP was not requested by the recipient.

The DAU decision date to close the medical review file is May 17, 2014.

The recipient receives full ODSP income support and benefits for the month of May 2014.

Income support is cancelled by the local ODSP Office, June 1, 2014, which is the first day of the month following the month of the DAU decision.

*Note. Should the MRP arrive at the DAU within 30 days past the MRP due date, the DAU will accept the
MRP and the person is to be reinstated to the date that income support and benefits were cancelled or reduced.

A spouse with a disability does not submit their MRP to the DAU within the prescribed 90-day time period.

The MRP due date is October 7, 2014..

The person contacts the DAU and requests an extension of time to submit the MRP. The DAU grants the request, and the MRP is now due January 6, 2015.

The DAU does not receive the MR DDP by January 6, 2015.

The DAU decision date to close the medical review file is January, 7, 2015, as the MRP was not submitted within the extension of time.

The benefit unit receives full ODSP income support and benefits for the month of January 2015.

Income support is reduced by the local ODSP office, February1, 2015 which is the first day of the month following the month of the DAU decision.

Continues to be Person with a Disability
A single recipient is found to continue to be a person with disability by the DAU on May 27, 2014.

The recipient continues to be eligible for ODSP income support and benefits provided they continue to meet all other eligibility criteria for ODSP.

 

Medical Review Scenario Impact on Income Support

No Longer a Person with a Disability

A single recipient is found to no longer be a person with a disability by the DAU on February 18, 2014.

Income support and benefits are cancelled by the local ODSP office, effective June 1, 2014, the first date of the fourth month following the date of the DAU’s decision..

This cancellation date includes a three-month transition period to assist the recipient in adjusting to the change in their financial circumstances. The three-month transition period is: March, April and May.

Internal Review Decision Upheld

A recipient with a disabled spouse is found to no longer be a person with a disability by the DAU on February 21, 2014.

An internal review is requested on March 3, 2014.

The DAU conducts the internal review on March 10, 2014, and confirms the decision; the recipient is no longer a person with a disability.

Income support remains reduced, effective June 1,
2014, the first day of the fourth month following the month of the DAU decision.

This reduction includes a three-month transition period to assist the recipient in adjusting to the change in their financial circumstances. The three-month transition period is: March, April and May.

Internal Review Decision Reversed

A single recipient is found to no longer be a person with a disability by the DAU on April 9, 2014.

The recipient requests an extension of time to request an internal review on September 18, 2014. The DAU grants the request.

The DAU conducts the internal review on September 22, 2014, and the person is now found to continue to be a person with a disability.

Income support and benefits are initially cancelled by the local ODSP office, effective August 1, 2014, the first day of the fourth month following the date of the DAU’s decision.

This cancellation date includes a three-month transition period to assist the recipient in adjusting to the change in their financial circumstances. The three-month transition period is: May, June and July.

Following the DAU’s internal review decision on September 22, 2014 that the person is found to continue to be a person with a disability, income support and benefits are reinstated by the local ODSP office retroactively to the effective date of cancellation, which is August 1, 2014.

 

Medical Review Scenario Impact on Income Support

SBT Appea. Grante.

A single recipient is found no longer to be a person with a disability by the DAU on June 15, 2014. Following a subsequent internal review he or she appeals to the SBT.

The SBT hears the case, and overturns the Director’s decision on February 14, 2015.

Income support and benefits are cancelled by the local ODSP office, effective October 1, 2014, the first day of the fourth month following the date of the DAU’s decision.

This cancellation date includes a three-month transition period to assist the recipient in adjusting to the change in their financial circumstances. The three-month transition period is: July, August and September.

Following the SBT decision, income support is reinstated by the local ODSP office retroactively to the effective date of cancellation, October 1, 2014.

Note: This assumes that there has been no interim assistance order by the SBT. Please note that that SBT can order interim assistance for recipients appealing a cancellation or reduction of income support due to a medical review.

Appealing a decision of financial ineligibility to the SBT e.g. income in excess

A single recipient is appealing a financial ineligibility decision to the SBT and is undergoing a medical review.

The SBT overturns the appeal and finds the person is financially eligible for ODSP on September 23, 2014.

As a result of the medical review, the DAU finds the person to no longer be a person with a disability on October 7, 2014.

The DAU’s decision date is October 7, 2014.

As a result of the medical review, the person no longer qualifies for ODSP income support and benefits as they do not meet all of the eligibility criteria under the ODSP Act, as they are no longer a person with a disability.

Income support and benefits are cancelled, effective February 1, 2015, the first date of the fourth month following the date of the DAU decision. .

This cancellation date includes a three-month transition period to assist the recipient in adjusting to the change in their financial circumstances. The three-month transition includes: November, December and January 2015.

Internal Review and Appeal Process for A Medical Review Decision

A medical review decision that a recipient or spouse is no longer a person with a disability is subject to an internal review and appealable to the SBT.

The DAU is responsible for conducting the internal review, providing written notice of the internal review decision and for filing a submission in response to a subsequent appeal to the SBT.

Recipients or spouses are encouraged to submit any additional or new medical information with their internal review request to the DAU. If the decision is appealed to the SBT, additional or new medical information may be submitted up to 30-days before the scheduled SBT hearing.

A recipient or spouse who previously qualified as a person with a disability can request interim assistance from the SBT. The SBT may order payment of interim assistance if it is satisfied that the recipient or spouse will experience financial hardship during the time it takes to complete the appeal and when other conditions of eligibility, other than those under appeal have been met.

If the appellant loses the appeal to the SBT, the amount of interim assistance that exceeds the amount the recipient would have been eligible to receive is considered an overpayment.

Issues Under Appeal

An appeal related to a decision that a person does not meet the definition of disability is handled by the DAU.

A recipient with a spouse with a disability, whose income support is reduced as a result of a medical review, can also appeal the reduction of income support. The local ODSP office would handle an appeal related to the calculation of the reduction of income support.

Related Directives:

1.1 Applications
1.4 Date of Grant
1.2 Disability Adjudication Process
13.1 Notice of Decision and Internal Review
13.2 Appeals
13.3 Recovery of Interim Assistance


1 - A psychiatric facility is a Schedule 1 facility designated under the Mental Health Act that is not a Provincial Psychiatric Hospital, a former Provincial Psychiatric Hospital, Homewood Health Centre, or the Centre for Addiction & Mental Health.