September 2017

9.10 Extended Health Benefits

Summary of Policy

Extended Health Benefits (EHB) are intended to reduce the impact of losing health benefits, and are available to the following three groups of individuals under section 45 of the ODSP General Regulation:

  1. An ODSP recipient whose income exceeds budgetary requirements if their eligible health costs are higher than the amount by which their income exceeds the budgetary requirements. The person must be otherwise eligible for income support.
  2. A person who on May 31, 1998 was receiving EHB under s. 15(4) of Family Benefits General Regulation if the person has income from a disability benefit under the Canada Pension Plan (CPP) or the Quebec Pension Plan (QPP) that results in income exceeding budgetary requirements and the person is otherwise eligible for income support.
    Note: This is a declining category. Those eligible under category (b) are those who were in receipt of EHB under s. 15(4) of the Family Benefits General Regulation on May 31, 1998. This group is composed of those persons receiving a Family Benefits allowance and CPP or QPP disability benefits in January 1987. These individuals were eligible for EHB under s. 15(4) of the Family Benefits General Regulation if the amount of their Family Benefits allowance payable in the month of January, 1987 would have been reduced to zero by reason of income that included CPP or QPP disability benefits.
  3. A person whose income exceeds budgetary requirements is eligible for EHB if the excess income is the result of a loss of income or loss of support payment made under the 1986-1990 Hepatitis C Settlement Agreement and the person was in receipt of social assistance on April 1, 1999. The person must be otherwise eligible for income support.

Legislative Authority

Sections 44(1), and 45 of the ODSP Regulation

Summary of Directive

In order to be eligible to receive EHB, individuals must qualify as a member of one of the three groups eligible for EHB.

Those in receipt of EHB must continue to otherwise be eligible for income support and must report any changes in their circumstances.

Intent of Policy

To assist ODSP recipients and members of the benefit unit with high health costs to become more self-sufficient by reducing the impact of losing health benefits as a result of income exceeding the budgetary requirements.

Application of Policy

The Extended Health Benefit includes:

  • Prescribed drugs covered under the Ontario Drug Benefit Plan and listed in the Drug Benefit Formulary;
  • Dental, Vision, and Hearing benefits;
  • Mandatory Special Necessities (MSN) including diabetic supplies, surgical supplies and dressings, and medical transportation costs;
  • The consumer co-payment for the Assistive Devices Program (ADP) administered by the Ministry of Health and Long-Term Care;
  • The cost of an assessment required to determine eligibility for an assistive device provided under ADP;
  • Periodic eye exams; and
  • The cost of batteries and necessary repairs for mobility devices.

It is important to note that recipients of EHB are not eligible for other benefits such as employment and training start-up benefit (ESUB), and up front child care costs, etc.

Eligibility

The following three groups qualify for EHB under s. 45 of the ODSP General Regulation:

A) Recipients who cease to be eligible for ODSP income support because of excess income but who have high health costs

A recipient is eligible for EHB even though their chargeable income exceeds their budgetary requirements if the total eligible health costs are greater than the amount by which their income exceeds the budgetary requirements. Chargeable income includes all non-exempt income, such as earnings and income from training after the earning exemption and deductions have been applied, CPP benefits, QPP benefits, Workplace Safety and Insurance Board (WSIB) benefits, Employment Insurance (EI) benefits, and any other type of non exempt payment. The person must otherwise be eligible for income support.

Where an item is covered by a private pension plan or health insurance, these items are not considered eligible health costs for the purposes of determining eligibility for EHB.

When a recipient is leaving ODSP as a result of income exceeding budgetary requirements, staff should enquire about the person's health costs to see if they may be eligible for EHB. If the recipient is not eligible for EHB, and has employment earnings/income, staff should review eligibility for the Transitional Health Benefit. See Directive 9.19 Transitional Health Benefit.

B) Individuals who received EHB under the Family Benefits General Regulation due to receipt of CPP or QPP disability benefits

A person who on May 31, 1998 was receiving EHB under s. 15 (4) of Family Benefits General Regulation if the person has income from a disability benefit under CPP or QPP that results in income exceeding budgetary requirements, and the person is otherwise eligible for income support.

Note - This is a declining category. Those eligible under category 2 are those who were in receipt of EHB under s. 15(4) of the Family Benefits General Regulation on May 31, 1998. This group is composed of those persons receiving a Family Benefits allowance and CPP or QPP disability benefits in January 1987. These individuals were eligible for EHB under s. 15(4) of the Family Benefits General Regulation if the amount of their Family Benefits allowance payable in the month of January, 1987 would have been reduced to zero by reason of income that included CPP or QPP disability benefits.

New cases cannot be granted under this category. Recipients who were grandparented onto ODSP income support from Family Benefits, including those who now cease to be eligible for income support because income exceeds budgetary requirements (including income from CPP/QPP) will be assessed under category (a), and possibly (c), if applicable.

C. Individuals who are ineligible for income support due to receipt of Loss of Income or Loss of Support Payments under the 1986-1990 Hepatitis C Settlement Agreement

A person whose income exceeds budgetary requirements is eligible for EHB if:

  • the excess income is the result of a loss of income or loss of support payment made under the 1986-1990 Hepatitis C Settlement Agreement;
  • the person is otherwise eligible for income support in the month; and
  • on April 1, 1999, the person was a member of the benefit unit under the Ontario Works Act, 1997; the Ontario Disability Support Program Act, 1997; or the Family Benefits Act.

There are no limits to how long a recipient may receive EHB under this provision. However, eligibility requirements must be maintained and the recipient must report any change in circumstances.

Examples

1. Single ODSP adjudicated recipient who is eligible for the maximum income support and has $1,199.00 in chargeable earnings

$662.00 - Basic Needs
$489.00 - Shelter
$1,151.00 - Budgetary Requirements
$1,199.00 - Chargeable Earnings
$48.00 - Excess Income Amount

The amount of chargeable income that exceeds the budgetary requirement is $48.00. The recipient is asked if they have any health related costs. The total costs for EHB eligible items would have to be greater than $48.00 in order for the recipient to qualify for EHB.

In this scenario, the recipient provides receipts for prescription drugs for one month which totals $52.85. Since the cost for the prescription drugs is greater than $48.00, the recipient would receive a dental card at the end of each month. The recipient is also eligible for the other benefits available under EHB. There would be no income support paid.

2. Single recipient eligible for the maximum income support who has $1,180.00 in chargeable earnings and monthly incontinence supplies costs of $192.00

$662.00 - Basic Needs
$489.00 - Shelter
$1,151.00 - Budgetary Requirements
$1,180.00 - Chargeable Earnings
$29.00 - Excess Income Amount

The amount of chargeable income that exceeds the budgetary requirements is $29.00. The total costs for EHB eligible items would have to be greater than $29.00 in order for the recipient to qualify for EHB.

In this case, the recipient has incontinence supply costs of $192.00. The recipient is issued a MSN benefit cheque of $192.00 a month, and would also receive a dental card at the end of each month, as well as other benefits available under EHB.

3. Single person granted EHB under s. 45(2) ODSP General Regulation. This person previously received EHB under s. 15(4) of Family Benefits General Regulation as income from CPP-D exceeded budgetary requirements in January 1987. This person continues to qualify for EHB even if health costs do not exceed excess income, if the CPP-D continues to result in income exceeding budgetary requirements.

$662.00 - Basic Needs
$489.00 - Shelter
$1,151.00 - Budgetary Requirements
$1,290.81(maximum monthly CPP-D benefit for 2016) - CPP-D Income
$139.81 - Excess Income Amount

Even though the recipient has income in excess of budgetary requirements, the recipient qualifies for EHB, as they fall under Group (b) as listed above. The recipient would receive a dental card at the end of each month, as well as other benefits available under EHB.

Special Circumstances

ODSP replacement schedules for glasses and hearing aids must be taken into account when completing the calculation (e.g.,glasses every 3 years for adults) and the cost averaged over the appropriate time period.

Yearly dental costs are averaged over a 12-month period.

Recipients with high drug costs who do not qualify for EHB can apply for the Ministry of Health and Long Term Care's Trillium Drug Program. Applications for the Trillium program can be obtained at pharmacies, or by calling the Trillium Drug Program at 1-800-575-5386.

Extended Health Benefit (EHB) and the Transitional Health Benefit (THB)

Recipients cannot access both EHB and THB. Recipients who become ineligible for ODSP due to income in excess from employment earnings should be assessed for eligibility under EHB first to determine if they qualify as the range of benefits is more comprehensive. If they are not eligible for EHB, then eligibility for THB must be reviewed. See Directive 9.19 Transitional Health Benefit.

Related Directives:

5.3 Deductions from Employment and Training Income
5.15 Spousal and Child Support
6.1 Basic Needs Calculation
6.2 Shelter Calculation
6.3 Board and Lodge
9.6 Assistive Devices
9.7 Dental Benefits
9.8 Drug Benefits
9.11 Hearing Aids
9.12 Mandatory Special Necessities
9.14 Vision Care Benefits
9.19 Transitional Health Benefit